The Midlife Midwife

Thanks

2010-03-28T19:15:00.000-06:00

I’ve been contemplating this post for awhile. I have decided to stop blogging. I started this blog three years ago and it has been a place for me to put my thoughts on paper. It’s given me a chance to meet new people and learn new skills. I’ve learned a lot from my readers.

Things have changed in the last three years. I’ve become much busier. I need to streamline my life and really decide what is most important. To be honest, I tell myself I am going to just write a quick blog post. But then I end up spending hours on the Internet writing and then reading all my favorite bloggers or exploring new ones. That isn’t a bad thing really. But when it interferes with my ability to get enough sleep, or keeps me from spending time with my family and friends it is a problem. “Virtual” relationships, be it on Blogger or Facebook, should never replace the real face to face relationships of my family or my friends. HIPAA restrictions have gotten much stricter at work. Blogging is not worth losing my job.

So as much as I have enjoyed these three years blogging, I am going to stop. I will probably leave the blog up for awhile. But eventually I plan on taking it down. Maybe I will compile it into a book to tuck away on my shelves and remind myself of these past three years.

Thank you to my readers. Thanks for your comments that have taught me. Thanks for your support. Thank you for the adventure. Oh. I almost forgot. Yes, the wedding went very well. All my children are officially married. I am officially an empty nester. Maybe that is why I feel a need to change my life right now.

Thoughts

2010-01-06T20:19:00.000-07:00

I am still here, just haven't blogged in a long time. I've been busy, but that's not the only reason. Just trying to decide if blogging is still something I want to do. I have lots of good things that keep me busy...too busy. I already cut out a lot of things and am now left with deciding on what "good" things to drop in order to maintain my sanity. HIPPA regulations at work are getting more strict. I think blogging about births is always interesting. Somehow blogging about endless pap smears, cranky patients and discharge isn't as interesting. I feel some responsibility to you, my readers, but for now....I think I am taking a writing hiatus. Maybe I will be back in March after I get my last child's wedding done!

December beginnings

2009-12-06T22:08:00.002-07:00

It is December! We put up our Christmas tree yesterday. One of my friends from work was moving to Florida and so she gave me her prelit Christmas tree. It is tall and very pretty. Plenty of room for all those family ornaments I’ve collected over the years. I always shed a few tears when I put on the little house that was on my mother’s tree when she was a child. I get wistful when I put up the ornaments from my childhood, and I treasure those hand made ornaments my children created many years ago. At the center of my tree are the picture ornaments of my grandchildren. I used to think, “Someday I am going to have a tree with color coordinated and matching ornaments.” Now I have come to realize that I cherish my tree where no two ornaments are exactly the same.

Thanksgiving Safari

2009-11-29T20:59:00.000-07:00

I did a non-traditional Thanksgiving this year. I went on a African safari....

If you are really quiet you can sneek up on the animals

I hung out with the elephants

watched the rhinos sunning under the trees

and pet a zebra.

Well, not really. My brother-in-law is making wooden puzzle animals for the grandchildren. I thought they were just too cute and had to get some pictures of them.

Hubby and I went camping with my sister and brother-in-law here...

My second son came up as well for a short visit. I loved my relaxing weekend. It was just what I needed!

Up late Update

2009-11-18T22:53:00.000-07:00

Not much to post. I've been too busy. 27 patients tomorrow, two procedures, two new OB's. I'm getting tired of running at full speed. I've taken to listening to music on my Blackberry when I drive to and from work. It helps me stay calm. I am back eating healthy again (and have the three pound weight loss to prove it). Can't find time to exercise but I am trying to be content with just getting back on track with my food. Trying to get my eight hours of sleep every night. I can tell the stress is getting to me because I am having a hard time sleeping. I am having vivid dreams and nightmares. And my neck and shoulders hurt all night. Usually a good sign that I am way too stressed.

I did have a wonderful weekend relaxing at Catalina Island with my brother and his wife. Spent Sunday in the mountains with friends. My soul needed that. I'm trying to realize that I have to change my expectations. My schedule isn't going to get better, patients will always come in with lots of problems on their annual exams. I need to stop getting frustrated about both of those. It's just the way work is right now. I'm trying to find the little joys in my day.

For instance: today my student saw all the patients for the morning. She is doing fantastic. I am having to give less and less direction. Today she inserted her first IUD and was so proud of herself. My postpartum mom was beaming and showing off her adorable baby girl. It was so great to share in her joy. I had a patient who is ready to address her weight issues and signed up for a weight management program. I had a great new OB couple who are from Russia and one from Mexico. I love having the telephone translation line. We got our next shipment of H1N1 vaccines so we can finish vaccinating our moms. We laughed so hard at lunch I had tears in my eyes (gallows humor, but a great stress reliever none the less).

This picture is of a flower that was growing by the side walk in Catalina. It reminds me to grow where I am planted. For now anyway, that's what I am trying to do.

hormone evaluations

2009-11-12T22:09:00.001-07:00

I tap in my password and hit the return key. The computer adds my electronic signature to the chart and I click onto the next patient on my schedule. Reason for visit: hormone consult. I sigh and begin to frame what I plan on saying to the patient about hormone testing, therapy, risks and benefits. I walk to my exam room and lift the papers out of the chart rack by the door. I turn them over and look at the name. I raise my hand to knock on the door and I see her age. 12 years old.

"I want her hormones checked. She has had two periods and they were more than a month apart. She is angry one minute and crying the next. She doesn't like boys but all her friends do and that makes her cry because all they want to talk about is boys. Her boobs have just exploded! She fights with me all the time and I am just tired of her. She needs to get her act together. She needs her hormones fixed because there is just something wrong with her. And she needs on birth control. I hate her....but it's OK honey, I really do still love you."

I stare at the mom in disbelief. I look at the girls eyes as they start to fill up with tears and then I see her turn angrily at her mother. "Well that's OK cuz I hate you anyway."

I spend the next twenty minutes explaining normal puberty, middle school angst, variable maturation rates of teenagers and try to explain why a hormone evaluation isn't needed. I also try to explain as gently as I can why birth control is a bad idea for a 12 year old who doesn't like boys yet and who is still developing. After they leave my office I don't know whether to laugh or cry. I spend five minutes tapping out a note about our visit. I tap in my password and hit the return key. Then I click onto the next patient on my schedule.

3 greatest challenges

2009-11-08T16:17:00.001-07:00

I think one of my greatest challenges is to try to educate and motivate my patients. Just like medicine can't heal the body, we can only support it while it heals itself. I can't help a patient heal unless they are willing and motivated to do their part. The best medications don't work if the patient doesn't take them. The greatest therapies or surgeries won't work if the patient doesn't want to do them. Educating a patient on their diagnosis doesn't work if the patient refuses to admit they have a problem. I struggle the most with three issues: Denial, non compliance (yes I hate that word but can't think of a better one) and lack of personal responsibility. I feel helpless at times to assist a patient in getting healthier, stronger, happier.

Denial: The diabetic who refuses to check her blood sugar, who says"But I am really healthy other than my diabetes" and then comes to see me because she is peeing all the time. She is sure it must be a bladder infection, or a problem with her bladder. It can't be that her blood sugar is elevated and that makes her kidney's overproduce urine in an attempt to lower her blood sugar. Her normal urine culture and large amounts of sugar in her urine don't convince her. The normal bladder exam doesn't convince her. She wants me to fix her problem. And gets upset when I say the way to fix it is to get her blood sugar under control. The teenager who doesn't want to believe she has placed herself at risk for an STD and doesn't want tested or to use condoms. And then cries six months later when I say she has Chlamydia or even worse, an STD I have no cure for.

Non Compliance: There is the woman who comes in pregnant and insists she was using birth control but then admits she decided she didn't like having to take a pill every day so she just took them when she had sex and can't figure out why she is pregnant. "The medicine you gave me just didn't work." is a common complaint...but they didn't take the medicine like they were instructed. You can't take a 10 day antibiotic for one day and expect it to cure your severe bladder infection. If you want to get better, you should probably come to your appointments. If you aren't getting better, you should probably come to your appointments so we can try a different treatment.

Lack of personal responsibility: The problems they are having are not their fault. They tell me it is my fault. Or it is their parents or spouses fault. I see a huge lack of willingness to accept personal responsibility for their own health. I see many patients who want an instant fix for their problems. They don't want to hear that it will take effort. They want instant cures, something that doesn't inconvenience them, isn't uncomfortable and that requires no effort on their part. If they didn't take the medicine, it isn't their fault. If they didn't go get a test done, it was because it wasn't convenient enough. Or the patient who "has to be seen right away" but can't make any of the appointment times we offer. Then tell us we are refusing them access to care.

What do I see in patients who do get better? Honesty, personal responsibility, and persistence. But that is a blog for another time...

Quotas and feeling angry

2009-11-02T23:05:00.003-07:00

It was a very busy day. I was so frustrated by the end because I feel so inadequate to keep up with the multiple demands. No matter how hard I try, I just can't seem to stay on time. I put in 10 hours today. Then because I am feeling inadequate, I begin to feel frustrated and angry at my patients. I begin to feel angry that they come to their annual exams with problems and concerns, that they don't get prenatal care until two weeks before their due date, that they show up 3 hours late for an appointment and I am still expected to see them (new office policy). So much of what I get frustrated at, they have no control over either. They can't hurry the Medicaid process that takes months to get insurance, they can't change the broken down car, or the illnesses that beset them.

I was listening to a news article on the radio a while back. It was talking about how workers in animal processing plants can fall into animal cruelty. The person said that because these people had to meet certain quota, they became angry and pushed the animals or hurt them just to make the quota. They weren't innately cruel people. But the time constraints made them see a balking or frightened animal as a barrier to doing their job. They became angry at those animals and so the anger made them feel more vindicated in what they were doing, even if they knew it was wrong.

I haven't been able to get that concept out of my mind. I am beginning to see just how true that is. I have a certain number of patients to see. I have to stay on time or face getting into trouble for not meeting my "quota" for the day. Patients give me bad reviews if I make them wait because I am running behind. A portion of my pay is a productivity bonus...see more patients, make more money. If I can't keep up, I get disciplined.
So today, all I could think about (in-between rushing around like crazy) was that I was succumbing to that same phenomenon. Trying to meet my quota, I was feeling more frustrated at any patient who took longer or slowed me down. It was all too easy to find fault with these women. It was easy to fall into the trap of complaining, or being short with them, or allowing anger to slip into my voice.

I hope I never get so busy that I can't fit in one of my cancer patients who just needed some reassurance and a simple test. Just to be able to see her and her courage, to give her a hug, and to see the pictures of her baby made my day so much better. That is why I do what I do. I just have to keep reminding myself of that. I am also going to keep resisting that urge to think that I can lower my personal standards of compassion, professionalism and human kindness just to meet a quota.

Colposcopy certificate

2009-10-26T22:37:00.001-06:00

Got my official certificate in the mail. I guess I must have passed the colposcopy test...whew! What a relief. Maybe now my life will settle down for a little bit? ha ha, that will be the day. I'm still so busy I can't see straight and can't find time to get enough sleep, much less blog.

Just found out today that the doctor we have been waiting a year for will not be joining our clinic after all. So my client load won't be getting any lighter any time too soon. I had been telling myself, "Just two more weeks and the new doctor will be here. I can hold out that long." Now the search for a replacement starts all over again and it will be months at the earliest before we get someone new. I am trying not to be discouraged or depressed. My boss keeps reminding me, "Being super busy means job security."

On another note, pregnant mom with breast cancer...everything is all squared away with surgeons, oncology, L&D and delivery date is set. Hope and pray it all goes smoothly. Pregnant mom with cervical cancer is doing well. Close monitoring until after delivery. Ended up not being invasive cancer...happy day! HIPPA being what it is, that's all I can say. I am just praying hard for both of them and their families.

Test is done

2009-10-20T22:35:00.001-06:00

I finally took my national colposcopy test today. I have had such a hard time finding time to study and didn't feel as prepared as I usually am for a test. But I needed to get it done. So I took it. I am keeping my fingers crossed. I may not know if I passed for up to 30 days from now....I hate waiting.

Flu shots

2009-10-15T22:21:00.001-06:00

People ask me all the time, "Are you going to get the H1N1 vaccine?" "Aren't you afraid there might be some horrible side effect like paralysis?" My answer? "Yes" and "Yes, I am a little nervous. I do worry about possible Guillain Barre' Syndrome. But getting my patient's sick because I was sick, or having one of my pregnant moms die as a result of the flu would be worse."

So I got my H1N1 flu shot today. I was first in line. I woke up this morning with a sore shoulder. So now I have two sore arms. But it will be worth it right? I do NOT want to pass that bug onto any of my pregnant moms. And wouldn't you know it? I had three of my six pregnant women today who had been diagnosed with H1N1 flu last week. Thankfully they are all doing much better today. Only one had to be hospitalized. It is going to be a LONG flu season. I think I should have bought stock in the companies that make hand sanitizer and Tamiflu.....

Big Black Cancer Cloud

2009-10-13T21:36:00.001-06:00

No, I haven't finished studying for my colposcopy exam. Plan on taking it next Tuesday. But tonight I just want to cry. Leaving work and checked my tasks. I got the biopsy results of one of my pregnant moms. Breast Cancer. So tomorrow have to make arrangements to tell her, get an amnio for fetal lung maturity, hopefully get her baby delivered early and then arrange for mastectomy, oncology care etc.

In the last couple months I have found 3 uterine cancers, 2 breast cancers, 1 cervical cancer. Enough already! I am getting overwhelmed. I have treated thousands of pregnant women and this is only the second who has had breast cancer. So I know it is a rare finding. But I am getting paranoid.

I did get a note today from one of my other (not pregnant) cancer patients. Her surgery is done, lymph nodes are clear, starting treatment. She sent me a sweet note about how much she appreciated my thorough assessments, working to get her care coordinated, and for sending her a get well card. I am glad that the small things mean a lot to them. I just don't like having to break the news to patients that their lives will never be the same.

Rain rain go away, come again some other day.....

Cancer update

2009-09-27T20:10:00.000-06:00

To those who have asked:

Yes, I did finally get to give the bad news to the pregnant mom with cervical cancer. It is never easy to do. It's hard and we both cried. She has been referred to the oncologist. Thankfully it is in a very early stage at this point. They may consider just doing a LEEP (shaving off top layer of cervix) during the pregnancy and do more treatment after delivery. Or they may not do anything until after delivery. I am leaving that up to the oncologists.

I did call her back 24 hours later just to check on her. I knew I had completely turned her world upside down and just wanted to let her know I was here to help if I could. It also gave her some time to assimilate the initial shock and be ready to ask questions and hear the answers.

On another note. I will not be posting in the next few weeks. I will be studying to take my national colposcopy exam. I had to figure out how to squish study time into my days and the only way to do that was to cut out the "non-essentials" in my life. I am cutting out Facebook time too.....think I may have withdrawals. :-)

Cancer

2009-09-22T22:24:00.002-06:00

How do you tell a young pregnant woman she has cervical cancer? I'll have to figure it out before tomorrow.

Multitasking

2009-09-21T21:52:00.001-06:00

I think one of the hardest things to learn as a provider is how to multitask. So many demands come at you from every direction during the day. It's hard to juggle all the tasks. Each time something new comes up, you have to quickly reprioritize. Today was a good example. I got to work this morning at 7:30 and this is what I faced:

24 patients on the schedule (one of my lightest schedules in a long time!)

4 e-mails

30 new tasks on the EMR. Two of the labs results were marked urgent

4 prescription renewal requests

Three new notices on the company website

So I started with the flagged lab results. One showed that one of my OB patients is critically ill. That took precedence over any other tasks. But I couldn't call the perinatologists until after 8 am. So I work on the other labs.

By 7:55 my first patient is in the room waiting to be seen. So do I see her first or wait 5 more minutes to call the perinatologist?

I see the first patient which takes longer than I had expected since she had a long list of problems to address during her annual exam.

Call the perinatologist but have to leave a message since she is with a patient

See my next patient and then get the call from the perinatologist during the exam. I have to prioritize quickly and excuse myself from the room to take the call.

Finish seeing patient.

Now I have to shift my day again to make time to call the on-call OB MD and also call the patient to have her proceed to the hospital to be admitted.

All day long it goes like that. I have to constantly figure out if it is more important to see my patients on time or take time out to answer a phone call, respond to an "urgent" message or call a patient about lab results.

During the day I get 15 more EMR tasks, five more e-mails, two more prescription renewal requests, one notice that I have mandatory on-line training for the new patient privacy laws, three patients show up at the front desk asking questions and requesting paperwork for school or FMLA. I get 3 messages from my MA with questions from patients. The administrator shows up to "chat". The new MD in family practice comes by to introduce herself, I have five new ultrasound reports to verify. I need to request a formulary override for a non-preferred drug. During this entire time I have patients to see.

And each patient visit requires prioritizing. Which of their multiple symptoms is important and which isn't? What lab results are the most important to get? Is it more important to use a generic drug for cost savings or to use a more effective medication? I have to weigh how much time to spend with a patient and when to tell them to come back for another appointment.

Then at the end of the day, when I leave work at 6 pm, I wonder why I am so frazzled. I've been pushed and pulled all day long like a ball of play dough. I'm getting better at it. Time and experience does that. But I am still learning. I look forward to the day when multitasking is no longer necessary though.

Stillness...awful stillness

2009-09-16T22:01:00.002-06:00

"I haven't felt my baby move today". That's what she said first.
"When did you feel the baby move last?"
She said "Night before last. Usually he is busy and moving all day long. Day before yesterday he was moving. Then that night he gave this huge kick and then a weird shaking motion. Then I haven't felt him at all since then."
"He hasn't moved at all today? Not even small movements?"
"No. I can't get him to move at all....is that bad?"
"Did you go into labor and delivery when you didn't feel him move yesterday?"
"No, I knew I had my appointment with you today so I just waited."
I can feel the blood start to leave my head and puddle in a great lump around my heart.
"Maybe he is just having a sleepy day. Sometimes that happens. Let's listen to his heart and see if we can get him to wake up."

There is nothing that compares to that absolute stillness you hear. No movement, no heartbeat. I gently shake her belly hoping that something will move. The stillness is there. I can feel the tears start to well up in my eyes and my throat constricts as I whisper, "Let's go into the ultrasound room". I know what I will find. I wonder how to break the horrible news and not make it seem like it is her fault. I know she had been instructed on kick counts. I know it probably wouldn't have helped even if she had gone in yesterday. I know she will blame herself. She will spend years wondering what she did wrong, or what she could have done differently. She will wonder all those "what if's". Cord accidents are sudden, unpredictable and thankfully very very rare.

I've never been able to hear the words "Still birth" without thinking those are the perfect words to describe it. Those babies are still. They doppler sounds are absolutely still. The ultrasound pictures are perfectly still. The babies come out still. They lay silently on the blankets. They are silent as we bathe them, dress them, and take those tiny little baby footprints. They lay still against there sobbing family's chests.

Still birth. It is two words that break this midwife's heart.

A little bit of Whine

2009-09-15T13:05:00.000-06:00

I really was doing better on my positive attitude stuff. But then last week I got busy with peaches (no exercise that week), then I've had a few back to back super busy days at work (eat chocolates and fast food on the run and gain back 4 pounds), then I had a flair up of sciatic pain (can't sleep because of pain). Then I do a big blog blunder (beat self up about it). Four firings and 60 layoffs at work last week (add more stress to worries). Today I am feeling drained, sad, discouraged, and trying hard not to beat myself up about it all.

I had the morning off work. So I went to my usual volunteer work in the morning. Then I came home, looked at all the good stuff I should have been doing and went and took a nap instead. When I am depressed, sleep is my drug of choice. I must have needed that little extra sleep because I am feeling a little better now. So I am off to work. Now if I can just figure out how to get back into exercising again...it is sooooo hard to restart once I quit. No wonder people make millions on "instant exericise" stuff that promises results with just five minutes a day. I'm ready for one of those "lay on our machine and it does all the exericse for you with no expenditure of energy from you". Sigh....only in my dreams. :-)

So pick myself up, brush myself off, and start all over again. No one said that progress was a straight line.

Judging patient's by their problem list

2009-09-14T22:40:00.000-06:00

I had a patient come in for a recheck today after surgery in the hospital. She was upset about her care while she was there. She has a history of some not so great choices in her life. She has really worked hard to overcome them and has made great progress. She has been so proud of herself. Sure she has had relapses, but she just keep working on her progress one small step at a time.

Her chart shows her labs and her problem list. The people who took care of her her in the hospital saw all that. And unfortunately, she felt that they treated her as if she was her past problem. I wish they could know her like I have come to know her over the last year. Raw lab data doesn't show her struggles or her courage. They looked at her chart and saw her problem list. But they didn't take the time to see all the notes showing her progress, or look at the recent labs that showed how far she has come in a short amount of time.

I wonder how many times I have been guilty of looking at a patient's problem list and defining them by their past. That's one of the reasons I love continuity of care. It takes time to get to know a patient. When I first met her, I had those judgemental thoughts too. But then I got to know her and saw that she was making progress. I guess I still have a long way to go. This is just another reminder to not judge a patient by their problem list.

I blew it

2009-09-13T21:21:00.000-06:00

OK, to those of you on blog readers, my personal e-mail got sent to my blog instead of out to my family....so if you got it, you know who I am. It's been deleted from the blog, but PLEASE be willing to delete it from you blog rolls and don't blow my cover OK? Thanks! (Note to self....double and triple check those e-mails!)

This is what I have been doing lately

2009-09-12T11:07:00.000-06:00

This is why I haven't blogged much this week. Every spare minute I was not at work I was doing peaches. Bottled peaches, peach jam, peach pie. I am tired and glad to see the bottom of the last box of peaches. I guess instead of pickles this year, everyone gets peaches for Christmas. Now all that is left is cleaning up the sticky kitchen mess....

Millions of peaches, peaches for me!

2009-09-08T23:07:00.000-06:00

I LOVE fresh peaches and it "tis the season". Went to visit my daughter at the farm over the weekend. We did a hundred quarts. Then I brought a bunch home with me. Hubby and I did 19 quarts after work today. I am exhausted. But I love, love, love peaches. So hubby will be doing up more peaches tomorrow night while I teach my prenatal class.

I know I can buy canned peaches, but they are never as good as the ones you bottle or freeze at home. Hmmmm, must be the midwife in me...it's just better natural or at home. ha ha.

officially old

2009-09-03T22:42:00.001-06:00

I must be officially old today. An AARP card came with my name on it.

Am I dreaming?

2009-09-02T22:06:00.001-06:00

I met a great couple today. Neither one smokes, drinks, or does drugs. They are married. She took prenatal vitamins and folic acid prior to getting pregnant. They came in for OB care starting in the first trimester. They are both in good health, eat well and exercise.

Wow, someone pinch me. I think I am dreaming. (I just had to ask...they are church going Baptists) I was very impressed with them both and I wish there were more of them in our practice.

MCAT happiness

2009-09-01T22:14:00.000-06:00

OK, I have to brag just a 'lil bit. My son just got MCAT scores back (medical school exam) and got a great score.....whooo hooo!!! Lots of studying and lots of hard work has paid off. :-)

Grateful for what I don't have

2009-08-31T22:31:00.000-06:00

I had to tell a patient today that she has cancer. It's never easy. Especially since I didn't get to tell her face to face. Tonight though I am saying a prayer that she will be blessed with comfort, courage and a cure. But I am also saying a prayer of gratitude that I don't have cancer. As bad as my day was, it is nothing compared to hers.

I saw cancer today

2009-08-29T00:19:00.002-06:00

I saw cancer today. I met it face to face. It was just a tiny ugly little lump tucked way back into a small space. A mushroom growing on human flesh. It seeped blood in a vain attempt to hide itself from view. I snipped it out with sharp strong instruments. It really doesn't matter what the biopsy says. We know it has spread...one vicious little cell at a time.

I saw cancer today. It was met with a tiny smile and a half shrug. It was an enemy from two decades ago. She shrugs her shoulders and says she is OK with it. She has lived a good and fulfilling life. Now she is just tired. She will face the end of her life the same way she lived it. With courage, good humor, occasional tears and her family close beside her.

I saw cancer today. Or maybe I should say...I didn't see cancer. I loved the relief that flowed from her voice and spread into my heart to warm it. She is still battling her cancer. But for today, the chemotherapy and her will to live are winning. The lump she felt is just a lump, nothing more.

I saw cancer today. But more than that, I saw three women. Wonderful, Strong, Amazing women. I am so very blessed.

I wish I was there

2009-08-27T21:55:00.001-06:00

Tonight I sat down to look at my son's personal essay for his medical school application. He has asked me to help edit his writing. As I read what he wrote, and piece together portions from his blog posts, I find myself close to tears. He is an amazing person. His compassion, determination, courage and intelligence are immense. I don't know how to help him distill all those wonderful qualities into a two page essay. How can what he write come even close to presenting the man he has become. It's a million small moments that have defined his life. No two pages can adequately portray that.

I know that school administrators spend mere seconds looking at an essay. I know they will look at his grade point average and think that distills his abilities into a single number. But they don't see the countless hours he spent out of school helping those around him. It doesn't come close to touching the pain that came from losing his best friend to cancer in high school. It can't show that he worked his way through college with very little outside support. They look at that one number and decide if they think he has the intelligence to handle medical school. I wish there was another number that could also show his level of compassion. I wish there were numbers to show his commitment, or his tenacity, or his courage, or his wonderful sense of humor.

My oldest son just started his second year in medical school today. He left his wife at the hospital with their newborn son. I hope his medical school knows what a great man they have in my son. I pray that they will see those qualities. That they won't beat him down with long hours, unhealthy lack of sleep, harsh and cruel criticism, or tear him away from his wife and children. He is a pillar of strength to his family and to me. He is one of the most intelligent people I know. He is dedicated to his family. He has a great wife to support him. I pray that his marriage will survive medical school. I pray that he gains knowledge but that in the process he doesn't lose his humility, humanity and compassion.

My daughter had a miscarriage today. She called me last night saying she was bleeding. I want to reach through the phone and hold her. I am seeing my patients today and can't help thinking, "Oh, she is as far along as my daughter is...was". I listen to those fetal heartbeats and my heart is just a little saddened today. My daughter is amazing. She is a very talented photographer. She is a terrific mother. She is fun loving, gregarious and has a wonderful ability to put people at ease.

I hate living so far way. I can't sit with my son as he fills out his medical school applications (and make him cookies to eat while he does it). I can't be with my new grandson to cuddle and hold him or to be amazed a just how big my granddaughter looks now that she is the older sister. I can't help my daughter in law cope with a new baby while her husband is at school. I can't hold my daughter, or do an ultrasound to confirm that everything is going as it should. I can't play with my other granddaughter to give my own daughter a chance to rest and recuperate.

I know my children are strong. I know they will grow and learn from these experiences. But darn it...I wish I was there.

The tiniest whisper of hope

2009-08-26T22:06:00.001-06:00

Today I got just the tiniest whisper of hope that I may someday be able to go back to catching babies. I was asked if I would ever consider going back to catching babies....my answer was a resounding YES! It's not much, but even the tiniest glimmer is wonderful. :-)

2009-08-25T21:31:00.001-06:00

9 pounds 7 ounces of pure joy

Yahoo! It's a great day

2009-08-25T21:29:00.000-06:00

The best part about today? That's easy...I am a grandma again! My son and daughter in law just had their second child, a big baby boy. He is almost three pounds heavier than his older sister was. He has such cute kissable cheeks. I can't wait to get to go see him in October. (No I can't go sooner...boo hoo).

Progress on my goals

2009-08-24T07:45:00.002-06:00

OK, here is how I am doing on my goals to be more positive. Here is what I am doing:

*I am still writing in my gratitude journal every day. I am enjoying that.

*I did write about something positive from my day four days last week

*I did take some time off to just look at the stars and relax, or sit out by my fish pond and listen to the waterfall.

I'm finding myself slipping back into old habits. Here's where I am falling behind:

*I rationalize that I don't have time to exercise. Last week I did OK on Monday but then started to do less time each night because it was late or I was "too busy". By the end of the week I wasn't doing it at all.

*I found myself sneaking in all those foods I know don't make me feel good in the long run. I ate the sugary and salty foods thinking that "just one treat to reward myself" was all I was going to do. ha ha I have the self discipline of a gnat once I start eating that stuff. So I find myself an hour later feeling badly, both physically and emotionally.

*I over committed myself. I found myself taking on just one more thing. "I don't want to hurt this persons feelings" or "If I accomplish one more thing in my day then I will start to feel better."

*I kept cutting back on my sleeping time figuring I would do just one more thing, or that I needed to exercise so I had to stay up late.

So here's my plan for the week:

*Get back with my original program. But also look at where I can change it so that it works better for me.

*Don't beat myself up about not being perfect

*Look closely and figure out where I can cut back

*Pray and mediate everyday and remember to ask for help so that "God will do for us what we couldn't do for ourselves". Its a 12 step motto I have forgotten recently.

I really do want to see some permanent change in myself. So I need to stick with it. Pick myself up, brush myself off and start all over again.

Star gazing

2009-08-20T22:41:00.004-06:00

I just need a break away from the office, away from my housework, away from all my responsibilities. Its the end of the week and I just needed a break. So my wonderful hubby was willing to go for a drive. We drove away from the house, away from work, away from the city, away from the freeway. We drove out into the dark and found a quiet spot to just sit and look at the milky way, watch the bats fly around, see satellites cross the night sky, and just forget the rest of the world existed.

My soul needed that today.

Favorite things for today

2009-08-19T21:26:00.002-06:00

*Seeing patient's for their third annual exam in a row...wow, I've been here that long?

*Little girls who clap their hands when they hear the baby heartbeat.

*Teaching the breastfeeding class tonight

*hugs from some of my favorite patients

*Splurging on an ice cream treat

*Funny thing for the day? I knew how to imitate the sound of whooping cough during the Grand Rounds lecture today. Who knew that I was so talented?

Strawberry Jam

2009-08-18T22:45:00.001-06:00

I had eleven girls from the young women's program at church over to my house tonight. I taught them how to make strawberry jam. It was noisy, it was crazy, it was sticky and it was lots of fun. They were so excited to each get to take a jar of jam home. There is nothing that compares to homemade bread slathered in hot new jam. Yum.

Can I really learn to like doing colposcopies?

2009-08-17T22:52:00.001-06:00

I didn't think I would ever like doing colposcopies. I had a new patient who has had abnormal pap smears for years. She has undergone multiple procedures and even had part of her cervix removed. Each time the pathology would come back normal. And every time the pap smears would still come back abnormal. She was pretty frustrated. I KNEW those abnormal cells had to be in there somewhere, I just needed to find them. I was a little fearful...I am still learning how to do this and am still nervous I won't do it correctly. Well, I looked and didn't see anything. So I moved my speculum, pushed the cervix around and still didn't find anything. So I tried again and BINGO! I found those abnormal cells. A white patch WAAAAAY back behind the cervix on the posterior wall. That tiny little patch of white made me want to shout and punch the air "EUREKA!". I took the biopsy and tried to remove as much of the abnormal cells as possible.

I walked out of that room and felt pretty pleased with my detective work and thought....Wow, that was fun! ( Now if I can just figure out how to make it less uncomfortable for my poor patients)

Practicing medicine

2009-08-14T22:22:00.001-06:00

It was one of those procedures that keeps me awake at night feeling terrible. The patient was sobbing even before she got in the room. She cried because she was terrified. She cried because she has had this done every year for a long time. It was a technically difficult procedure. The instrument had a malfunction and rather than it being an easy one step procedure I had to keep trying. Once I figured out the problem was the malfunctioning instrument I was sweating profusely and feeling about the size of a stepped on grape. The second instrument was much better. The patient was in tears but thanked me profusely for being so understanding and kind. I felt like a total fraud because it had been difficult.

I hate inflicting pain even when I know it is necessary. I couldn't sleep mulling it over in my mind all night searching for ways to prevent the same problem, to reduce the pain next time, to fight to get new instruments from a cash strapped company.

Today the results came back. I called her on the phone and her voice shook when she heard it was me. She was already starting to cry. I told her I had good news. It wasn't the disease she so dreaded. She cried tears of joy. She took great shuddering breaths like it was the first time she had taken a deep breath in days. She thanked me over and over. I apologized for it being so hard and for not being able to make it easier. She said it was OK. If she has to repeat this next year, we made a plan to help with the pain. I wrote our plan in her chart so next year I won't forget.

I won't forget her. I learn so much from my patients. I learn at their expense sometimes. Their pain teaches me. I appreciate them being willing to let me practice medicine...really practice until I get it right. Those hard procedures, those difficult talks, those sleepless nights mulling problems over in my head, they all teach me to become a better practitioner. Today I am grateful for my patients: their sacrifices large and small, their courage, and their forgiveness that helps me learn.

Back up

2009-08-14T07:26:00.001-06:00

Today I am glad that I work with the physician I do. There are a few things I really appreciate about him. He is always kind and compassionate to our patients. He is always willing to answer any questions or concerned I have, even if that means answering his cell phone in the middle of a meeting if I call. He knows I only call if I really need some help. But the best thing about him? He appreciates me and will always back me up. He doesn't treat me like a second class citizen because I am not a doctor. He values my education and expertise. And he is willing to back me up when a patient questions why they "had" to see me first. So when a patient sees him for a consult after seeing me and says, "I don't understand why I had to see her first. She didn't do anything for me except run a bunch of tests and then send me to see you. She was a total waste of my time." He explains that he would have done the same tests as I did. And that he is glad he has me to work with because I help the patients get exceptional care. He trusts my judgment and they were privileged to see me first. Wow, how is that for a back up physician! Yes, it really did happen that way. I heard it!

Love, Love, Love teaching

2009-08-12T21:49:00.001-06:00

Ahhh, long day but a good ending. I taught another pregnancy and childbirth class tonight. I love, love, love to teach. I love being able to give these couples the power that comes from being educated consumers. I love laughing with them. I love seeing the lights go on when they understand something they didn't know before. I love seeing their curiosity, their thirst for knowledge, their willingness to express their thoughts, fears and joys. I love watching them interact with each other and share their stories. I love being able to share with them the normalcy of birth, the wonderful things their bodies are capable of, and to help them not be afraid.

I am so grateful that my company has been willing to put these classes together and offer them to their clients for free. Ahhhh, I am so blessed.

Todays favorite

2009-08-11T19:29:00.004-06:00

I love continuity of care. I love that I have been with this job long enough that one of my favorite patients is back to see me for her second pregnancy. It makes me look forward to the next eight months because I know I will get to see her often.

I brought in a vase with flowers to work. I figured that flowers would help brighten up my office and help me stay more positive. Actually, I went one step better. I gave the flowers to one of the other providers who is struggling right now. I can still enjoy the flowers every day, but I also get the added joy of knowing it will help them feel more cheerful as well.

Progress report

2009-08-10T20:37:00.004-06:00

So have you been wondering how I have been doing on my plan to be more positive at work? In the last seven days I have written in my gratitude journal six days, exercised four, blogged positive things five times and eaten good food for five days. I have to say it has been working. I've been trying very hard at work to not say negative things. I am not perfect by any means but I am doing much better. And I am feeling much better. Today I had a busy day: back to back patients, and all my annual exams where also problem visits. I did pretty good, I had a good time at work, and I was finished only 15 minutes after 5 tonight. Amazing what an attitude change can do for my productivity. :-)

So here is my gratitude and happy stuff for today....

I received the beautiful scarf made by my blogging buddy
Awesome Mom
Isn't she so talented? I love the fire like colors.

Happiness is the first water lily in my fish pond.

Gentle ladies

2009-08-07T22:52:00.000-06:00

My favorite patient today was a "little old lady". She is approaching her 80's and came to me for a colposcopy. She is delicate and frail. I love these ladies. They grew up in a more gentle society than today. She was very polite and made sure that she called me by my title. I made sure I called her "Mrs.". We had a lovely conversation before I started. She told me she was grateful to me for helping her solve her problems. She told me it was OK to take my time because she knew I needed to look closely and she wanted be sure she got the correct treatment. She said she knew that "pain is a part of the process". No whining, no complaining. Just polite conversation and gratitude. I suppose it is her attitude that has helped make her a cancer survivor. I hope I grow up to be just like her.

We just can't do this!

2009-08-06T22:38:00.002-06:00

“We just can’t do this! Can you guarantee our baby is OK? I don’t want to do this again. Refer us for an abortion now!” The couple looked at me with tears in their eyes. The man’s face was angry and his voice was rising. “Why can’t you tell if our baby is OK?”

I moved the ultrasound wand back across the woman’s belly. The little baby was waving its arms and turning summersaults inside the uterus. The heartbeat was beating out a quick staccato.

“I can’t tell at this point if your baby has a genetic defect. It’s too early to see the markers. And the only way to tell for sure if your baby had a genetic defect is to do a chorionic villis sample. I already have your appointment set up to see the perinatologist next week. They will do the procedure and you should have results back in a couple weeks. That will still give you enough time to do a termination if the baby had a defect.”

“I don’t care anymore, I just want this baby out and over with.” The man was leaning over towards my face and his face was getting red. “I can’t bury another baby! You just don’t understand.” The wife was quietly weeping and staring at the moving baby on the screen.

“You are right, I don’t understand what you are going through. I haven’t had to bury any of my babies, and I have not had multiple miscarriages either. But I can’t tell you if your baby is OK or not. Only genetic testing will do that. There is a chance this baby is normal. And there is a chance this baby has a defect. Are you willing to wait a couple more weeks to find out whether you are going to terminate a normal baby?”

The couple eventually walked out of the office. The man was starting to talk more loudly. “We won’t be back. You will see. I can’t believe you won’t tell me what I want to know! You are the doctor; you are supposed to know these things.”

My heart hurt for this couple. I tried very hard not to get angry back at this man as he got more out of control. I knew this was just a grief reaction. The uncertainty was the hardest part. The possibility of another miscarriage or another baby who would die shortly after birth was more than they could emotionally handle. They could see the tiny baby with little arms and legs. They wanted to hope but were so afraid of another loss to add to their unbearable losses. I had done my best to explain their options. I had done my best to try and get them to hang on long enough to get answers so they wouldn’t always wonder if they had made the right decision. I worried though that I had asked them to put up with a few more weeks of uncertainty just to make them hurt even worse if the baby did have a defect.

I didn’t hear back from them. Their next appointment came and went. They didn’t show up. A few weeks later I got a report from the perinatologist. The chromosome studies where back and they showed a normal male. No genetic defect was found.

I still didn’t see them the next month. But the following month the woman was back for a prenatal check up. She was quiet and withdrawn. Now that she was past the danger point of a miscarriage she was back for prenatal care. She said she was feeling indifferent to this baby. She didn’t want to get her hopes up. She said her marriage was struggling under the strain. I sat with her and we talked about how hard it was to get attached to a baby you may lose. She had loved and lost multiple times before.

A month later she was back. She asked to have her records transferred to another doctor. “It’s nothing personal. I just need to go someplace different for this pregnancy. I can’t come to this office with all the memories of my other babies.” I wondered if I had let her down.

It’s been about eight months since I had seen her last. She came to see me today. Her smile was bright enough to chase away any clouds in my day. “Come to the waiting room. You have to meet him!” She hurried back to the waiting room where her husband was holding a chubby baby boy. “He is just perfect!” her husband beamed.

They never said thank you. They aren't coming back to see me for their OB/GYN care. They just wanted me to see the baby. It was OK. Their happy faces and watching them look adoringly at their chubby baby boy was enough thanks. Those looks said it all. They had dug deep into their souls and took one more dangerous chance and they won.

As they left I can still remember that day. “We just can’t do this!” Yes, you can.

Caught up

2009-08-05T21:36:00.000-06:00

I had a few "no shows" today. Those extra minutes were sure nice. I managed to get all my charts signed off, people called back and filing done. Ahhhh. It feels nice to be caught up. What was the best part of the day? My medical assistant went back on Chantix so she can stop smoking again. I am so proud of her. I love having her as my assistant and I want her to stay healthy for a LONG LONG time.

Home Health Nurse

2009-08-04T22:04:00.001-06:00

One of my new patients today was a home health nurse. I like having nurses for patients. She came in with her medical history, family history, medication list, and a list of all her surgeries. She brought in copies of her last pap smear results. She has a great sense of humor and it was fun to "talk shop" during the exam. She was cheerful and polite.

One of the best things? She came in with a list of questions she had answered about her problems. They included:

How long ago did it start

How long has it lasted

What makes it better

What makes it worse

What she has already tried to make it better

How would you describe it (sharp, dull, aching)

What proceeds the symptoms (eating, constipation etc)

Has she ever had these symptoms before

What did she think it was

In about two minutes she was able to give me a quick overview of her problem. She had done most of the "detective work" for me. So even though this was a problem visit and an annual exam, it didn't take very long. I was able to order the appropriate labs and prescribe the medications to help. It only took an extra few minutes. And on a day when I was double booked; she was very much appreciated!

My great M.A.

2009-08-03T20:42:00.000-06:00

Today went well because I have the best medical assistant. I had a patient who has two of the busiest little children. Last time she saw me, the kids managed to dismantle my computer. Today she came with both kids again for an office procedure and an annual exam. My medical assistant is so amazing. She got the patient back in record time, had the room set up (including putting all the computer stuff out of the reach of little fingers) and helped me do the procedure. We did the procedure, did the annual exam, entertained the kids and did it all in less than 20 minutes. Wow! And the most amazing part was she kid proofed the room enough, talked to the kids enough, the kids were able to stay quiet enough, that they "earned" the stickers she promised them for being good. (OK that last sentence was poor grammar....but my M.A. is amazing!)

My Goal...there I've said it

2009-08-01T21:09:00.002-06:00

Something about myself really bothers me. So I am going to try to do something about it. I guess the first part of making a change is to admit the problem. So here it goes....

I am prone to a negative attitude. Especially at work. I find myself getting frustrated easily. I walk into work, look at my schedule for the day and immediately start to envision all the things that can go wrong. I look at a patient's history and begin to feel overwhelmed or frustrated and I haven't even met the patient yet. If one of my coworkers make a negative comment, I can think of five more to add to the list of complaints. I allow their negative comments to set me into a negative tail spin. I waste a lot of energy by letting the negativity into my day. Yes, it is crazy busy at work right now. But my negative attitude uses up energy I could be putting toward getting through my day. My negative attitude enhances my prejudices. It blinds me to the good in my patients. I blinds me to the good I do every day.

The next step is to admit to what "tapes" I play in my head that fuels my negative attitude. Things like:

*I am supposed to be able to solve all my patient's problems and always be able to make a diagnosis immediately.
*I shouldn't have to work this hard.
*My patients are never going to change and I am wasting my time.
*I have to work so hard and so fast I am going to make a mistake and ruin my career or some one's life.
*Complaining will make me feel better by "blowing off steam"
*Complaining with my coworkers give us something to bond over.
*Things are just going to keep getting worse. Health care reform will just make us do more with less...just like it has always been.

What else contributes to my negative attitude?

*lack of adequate sleep
*eating unhealthy food
*Over committing myself
*Not knowing enough

So one of the parts of wanting to change is to get the word out so that I am accountable to someone else. So you are it. Here's my goal:

Become a more positive, optimistic person. When I have a positive attitude: I am more receptive to my patients, I am a better listener, I am more compassionate. When I have a positive attitude I stick up for myself and set realistic boundaries and expectations. Attitudes are contagious and I want to promote a positive work environment that is healing for myself, my coworkers and my patients.

Here's how I plan to work on my goal:

Be to bed by 9 pm so I can get up at 5 to exercise. I am worth taking care of.
Spend a few minutes a day writing down things I am grateful for.
Write each day one thing that went right at work.
Go back on my healthy diet and be honest with myself and quit fudging.
Stop myself when I find negative words coming out of my mouth.
Change my "tapes" to more positive ones.
Spend a few minutes each day reading a journal article or reading a little bit in my medical texts.

I know I won't be perfect at this. I know I will fall down at times. But at least I can keep trying to go in the right direction. Thanks to my son and husband for listening to motivational tapes while we drive. I'll try and put it all into practice. This was my first step.

Pediatric mechanic

2009-07-25T07:36:00.002-06:00

We are on our long drive home after helping move my son. On the way home, our trailer had a flat tire. We pulled into the closest small town to get it fixed. We stopped at the service station. Interesting experience that turned out to be.

Turns out that the mechanic who helped us with our tire is a pediatrician. Really. He says he got fed up with being overworked, not being able to provide the medical care that was needed because it wasn't covered by insurance, having to "pull the plug on too many little kids", not getting reimbursed for his work from the insurance companies, having to wait up to six months to get paid, and the stress of it all.

He had been a mechanic before medical school and last year he gave up his medical practice, bought the gas station in this small town and says he is so much happier. He pumps gas, fixes cars and provides "drive by" medical advise to some of his favorite customers...and the in the meantime still managed to save a couple lives.

Interesting. I can't say I haven't thought about giving it all up and going back to being a domestic engineer.

Lost and Found

2009-07-23T14:19:00.004-06:00

It's the little things that seem to create the best memories for me. It was a little thing, but it will be one of those memories this mom's heart remembers. We had gone to a restaurant with my son, his wife and our granddaughter. My granddaughter was toddling back and forth from our table to the empty booths behind us while we waited for our dinner. I enjoyed watching her explore. We thought the booths were empty but then I noticed my granddaughter was reaching out to touch a pair of shoes that just peeked out from the booth.

I had noticed the little boy before. He had walked past us and sat in the booth with a kind of frown on his face. I assumed he was pouting about something and had sat at a different table than his family. There were a few families sitting in the tables around us. The families had eaten and left. I hadn't realized the young boy was still in the booth.

My son got up to go pick up his daughter. He brought her back and set her in the highchair. I asked about the boy and my son said the boy was crying. " I wonder if he made a wrong turn and got lost in the restaurant" My son went back over to the booth and spoke with the young boy. I could see them talking and then my son took the young boy by the hand and said, "I'll help you find your mom."

My son walked with the boy. I watched as my son talked to the boy as they explored each room in the restaurant. They disappeared out of sight and my son came back a few minutes later by himself. They had found the boy's family.

We saw the boy and his family as we left the restaurant. The boy was smiling and teasing his sister. He was laughing and seemed to have recovered from the tears that came from being separated from his family.

It wasn't a big deal. My son did it without even thinking. It made me grateful that he has turned out to be a compassionate and caring man. It is one of those memories I will cherish.

Crazy Week!

2009-07-16T21:27:00.003-06:00

I have been putting in 11-13 hours days this week. To say the office has been crazy is an understatement. Weeks like this and I am ready to quit and be a housewife again. I know this is only temporary. I am off again next week to help my son and family move across country to finish up his last years at medical school. I just have to survive one more day at the office....

While I am gone, here is one of my favorite photographers and a great fundraiser for a little girl who is battling cancer. Check it out here

Girl's camp adventures

2009-07-12T22:56:00.002-06:00

I just spent the last week up in the mountains volunteering as the “camp nurse” for a church girl’s camp. I went up with the girl’s I am responsible for at church. All total there was about 200 young women and leaders at camp. It was a crazy busy week but I really enjoyed it.

I had all sorts of medical and not-so-medical problems to take care of up at camp. Lots of girls with nausea and vomiting (some who stayed overnight in my tent so I could watch over them all night). Dehydration, altitude sickness, muscle strains, menstrual cramps, headaches, stomach aches and the like. I did send a few girls off the mountain due to medical problems. I even got to stitch up a knife wound….note to mom’s out there. Don’t pack steak knives in girl’s luggage. They just might kneel on the luggage and get stabbed.

It was lots of work. I didn’t get a lot of sleep. I got just as dirty as the girls did. We were only allowed one shower all week. Baby wipes were my best friend since I could do a “spit bath” with them every morning. I ran up and down that mountain multiple times a day carrying my first aid pack with about 25 pounds of equipment and supplies. I slept in a tent all week. I lost a few pounds.

There are a couple memories I will always cherish and that still warm my heart. I think they mean so much because they meld my experience as a mother with my experience as a midwife and nurse practitioner.

One of the girls began vomiting the first night at camp. This was her first year at camp and she was scared. I loved being able to stroke her forehead and calm her down. She spent the night in my tent. She was fine by morning. Every time she would see me in camp after that she would run up and give me a big hug and a smile. She was my “tent buddy” and had a great experience at camp.

The other moment that is burned in my memory is being able to hold a girl who had seizures. She has epilepsy but none of her friends at camp knew that. She had a seizure in front of all the girls. I held her after her seizure while she cried because she was embarrassed that now everyone knew her condition and she just wanted to fit in and be “normal”. I held her and rocked her after her seizures hit again and during the post seizure state when she was not totally coherent. And I gave her a final hug when we loaded her into the vehicle to evacuate her off the mountain. She is a teenager, but still needed someone to hold her and rock her and let her cry.

There is something so wonderful about being able to give COMFORT. Yes, my medical skills were needed. But what I will cherish the most was the chance to offer comfort to these girls. Some of them just needed a mom to give them a hug or to tell them that it was going to be OK.

Once again I am amazed at the strength of women. These young women are amazing. They were courageous, kind, willing to try new things, faced their fears and overcame them. They learned to shoot a bow and shoot guns. They went down zip lines and climbed up rock walls. They hiked further than they thought possible. And they were reminded that they are special women who are loved and cared about. They learned that God loves them and that they have tremendous potential.

I am going back next year.

girl's camp

2009-07-07T07:55:00.002-06:00

I am off to voluteer as the camp nurse at a church girl's camp for the next week. I will see you next week!

Midlife Midwife

Snow in June

2009-06-30T22:21:00.003-06:00

Remember when you used to make snowmen when you were a kid? You started out with a small ball of snow and you rolled it around on the snow. With each turn of the ball, it would get bigger and bigger.

That’s how my days have gone at work this week. I started off OK but as the day rolled on, I get further and further behind. My work load just seems to get bigger and bigger. Here’s how my afternoon went today:

I started off with 13 patients, 10 annual exams, one new OB physical and two return OB’s. Busy but certainly do-able. The first exam she also complains of a vaginal infection so it took just a few extra minutes to get an extra culture swab and to order medications. The second one wanted to talk about birth control because she doesn’t remember her pills. So an extra 5-7 minutes talking to her about alternatives and scheduling for an IUD. The third one also had irregular bleeding, the fourth had pelvic pain, the fifth had a vaginal infection and a bladder infection. Halfway through my afternoon those extra minutes are adding up.

And just like the snow ball gets bigger faster, my days have gone downhill even faster as the day wears on. Every annual exam was also a problem visit….pelvic pain, low libido, heavy bleeding with severe anemia, osteoporosis with a fracture, dyspareunia and the list kept getting longer. That new OB has an ugly OB history and requires referrals to the specialist, extra lab work, EKG and eye exam referrals. One of my return OB’s had never gotten her pap smear. So instead of a quick exam, I did a whole physical exam as well. And the last OB I can’t find heart tones and then have to tell her she lost her baby.

In and of themselves, each extra little problem wasn’t a problem at all. But added all together, by the end of the afternoon I was running an hour behind. I stayed after work 1½ hours to finish up all the charting, lab work, signing off charts, returning patient’s phone calls and reviewing ultrasounds.

Too bad that snowball doesn’t help me feel any cooler in the summer heat.

2009-06-28T21:07:00.001-06:00

“We walk quietly. ….We sing a prayer song”. I was three years old and that was my first memorized talk I gave to a church congregation during our children’s program. That was the first of an uncounted number of times I have spoken in front of groups.

One of the nice (albeit scary!) parts of being a member of my church is we have lots of opportunities to speak in front of groups. I’ve had multiple opportunities to teach classes and give talks.

Between school and church, I was taught how to outline a talk, how to speak slowly and clearly, how to interject some humor, and how to smile and interact with an audience. Years of being in the theater taught me how to “act” as if I am calm and collected in front of an audience.

All that training paid off in a big way this week. I was asked to teach the breastfeeding class at work. Someone else was supposed to do it but couldn’t at the last moment. I was reassured that they had a video to play and I would just need to answer any questions afterwards. I spent six years doing breast feeding support in the postpartum units and nursed all three of my children so I felt comfortable in doing that.

I got to the class and right before the class I asked if we could check the audio visual equipment. Well guess what, the laptop’s DVD player had been disabled. NO VIDEO. Panic was a mild word for what I felt.

That’s when all those years of practicing, making mistakes, learning to act calm, giving speeches and teaching lessons came into play. I was able to stand up and teach for one hour. No notes, no outline, no props, no audio visuals, only me. And I did it! The pregnant couples seemed to enjoy it and they learned.

So to all those teachers, my parents, my friends, my acting coaches, my church leaders and all those students I taught: Thanks for teaching me how to do this. Thanks for all those hard experiences and scary times that made it so I could teach a class like this.

Sky diving

2009-06-22T21:47:00.002-06:00

I had a cute octogenarian (that's a fancy way of saying she was over 80 years old) see me. When I reviewed her medical record, I saw that she had broken both her ankles at the same time in the last year. Here's how the conversation went....

MM: I see you broke both your ankles. How did you do that?

Cute Lady: I broke them when I went sky diving.

MM: Really?!!

Cute Lady: No, not really. But it sounds so much better than saying that I got up in the middle of the night and tripped in my bathroom.

I couldn't stop giggling about that one.

Problems with teens and birth control

2009-06-09T22:38:00.001-06:00

Teen: I am here to get on birth control

MM: how long have you been having sex?

Teen: For about three months, but I have been careful. Can you do a pregnancy test?

MM: Yes, we can do a test before you leave today. Have you used condoms every time you had sex?

Teen: No. We don't like them. They make me itch.

MM: You do realize that condoms are the best way to prevent sexually transmitted diseases right? If you have a reaction to latex condoms you can use non-latex ones.

Teen: yes, but I won't get any diseases. I've only had sex with one person.

MM: How many other girls has your boyfriend had sex with before you?

Teen: Only five. But he didn't stay with them. He says I am his one and only. He was tested for HIV and he was negative.

MM: Was he tested for Chlamydia, gonorrhea, trichomonas, herpes, Hep B, syphilis?

Teen: I don't know. Why should he? He doesn't have anything, he said so. Besides, I've only had sex with him.

MM: But he had sex with five other girls...and who knows how many other sex partners those girls had. Essentially, when you had sex with him, you exposed yourself to whatever diseases those other people had. I would suggest that you get tested today for STD's. STD's are caused by germs that are too small to see so you can't tell you have them unless you are tested. You don't have to have a pelvic exam. We can do the testing by blood and urine tests.

Teen: I am not trampy. Aren't you proud of me for only having one partner? (getting angry) You should be telling me what a good girl I am. Not lecturing me. All my other girlfriends have had sex with ten or so guys.

MM: Yes, you are a lower risk because you have only had one partner, but even one can give you a disease. You still need tested.

Teen: I know he doesn't have anything. I don't need tested and so I won't do them.

MM: OK, so you don't want to do the testing. So lets talk about birth control.

Teen: I don't want to do the shots, they make you fat. All my girl friends are fat. I don't like pills. Besides I am too busy to take them.

MM: So what about the patch or a ring? You don't have to remember them every day.

Teen: I can't wear a patch, people would see it and think I was having sex.

MM: But you are having sex. You can put it where people can't see it.

Teen: Not with my bikini's I can't

MM: How about the ring?

Teen: gross, I can't put something in myself.

MM: Let me show you the IUD or the Implanon device.

Teen: Will they hurt?

MM: You might have a little discomfort when they are inserted but I use medicine to numb you up.

Teen: I won't do anything that hurts!

MM: Having a baby hurts more.

Teen: That's why I am here. I don't want any babies. I want something that is 100 % accurate.

MM: Oh, that's easy. Don't have sex. That's the only 100 % accurate form of birth control

Teen: I didn't come her for a religious lecture.

MM: It has nothing to do with religion. It has to do with the most effective birth control. You asked for 100% effective.

Teen: (angry) you can stop lecturing me!

MM: OK, so what birth control would you like to try?

Teen: I don't like any you said. I want something else.

MM: Well, I've outlined all of your options.

Teen: Gross. I don't like any of them. So find me something.

MM: I've given you all your options.

Teen: But I don't like them. You are supposed to get me on birth control.

MM: I don't have anything else to offer.

Teen: (very angry) So you are saying that I wasted my entire time her today? I can't believe you are refusing to give me anything. Do I get my money back?

MM: I am not refusing. I gave you your choices and you have to choose one of them.

Teen: If I get pregnant it is all your fault then.

MM: No, it is not my fault. You are the one having sex. You do the adult behaviors, you have to take the adult responsibilities.

Teen: I am responsible. I am careful. I am going to report you to my insurance company because you are refusing to give me birth control. Get out of here!

MM: OK, here are your checkout papers. If you decide you want to start on a birth control come back and see me and I will get you started. I would still recommend you use condoms to help prevent pregnancy and STD's. Stop off at the lab and we can do your pregnancy test.

Teen: Forget it! I am never coming back. You are just stupid.

Sigh, I just don't know what to say sometimes. I just find these visits so sad. Because the next patient the same age came in because she was pregnant and just can't figure out "how it happened". Thank goodness I do have some responsible and amazing teenage patients.

Four minute update

2009-06-08T07:30:00.001-06:00

I have four minutes to blog before I have to get going to work. This weekend was great. Drove interstate to attend my granddaughter's first birthday. So much fun. I thought I might get a chance to catch my niece's first baby, but alas...babies never come when you want them to. That was the only sad part of the weekend (well that and the ten hours of driving...I'm getting too old to sit that long!) ooops, minutes are up. Have a great day today.

Teens and a long day

2009-06-04T20:47:00.002-06:00

Crazy day at work again. Other practitioner still out sick. So I'm trying to absorb the overflow patients. So at the end of a long day today that meant I had six patients scheduled in the last half hour of the day. I didn't get off until late again. Add that to having a patient screaming and throwing fits that we don't take her insurance. She was screaming that the reason we wouldn't see her is because we are racist...I hate it when they throw that at us. It has nothing to do with race, it has everything to do with not being paid and for getting in trouble with the insurance companies if we do see them. I had to stop seeing patients to go up to handle the altercation at the front desk. But by the time I got up there, security had escorted her out. I guess today was the day for upset patients as she was the second one today.

Ok, I promised to write about my teenagers. Here they are:

13 year old: came in for breast exam. She has been watching TV and two of her favorite shows had young women who had breast lumps...one had breast cancer, the other leukemia. So she came in because she was scared. I could reassure her she was fine. Told her to stop watching TV.

15 year old: came in for consult. She had been treated by her pediatrician for three sexually transmitted diseases. She told me that was impossible since she only has sex with her girlfriends. I reassured her she was wrong. Long discussion on safer sex practices. Told her to stop having sex until all of her girlfriends had been treated.

18 year old: came in to verify pregnancy. No problem. She is 39 weeks along and due next week. I could verify she was pregnant. This is her fourth baby in 4 years. She complains she keeps getting pregnant and she doesn't want to. Reassured she was indeed pregnant. Told her to keep her postpartum appointment so she can get an IUD or Implanon inserted. Wrote order on chart to give her Depo injection before she leaves hospital after delivery. Spent time making sure abuse is not a factor in her unplanned pregnancies.

I whine sometimes about all the time I spend being the president of the young women's organization at church. I complain that it takes up my Sundays, Tuesdays and Thursdays for teaching, activities and volleyball games. But I have made a new commitment to stop whining. These girls need me. I am so grateful for the chance to teach them morals, values and give them something fun and worthwhile to do with their spare time instead of having sex.

Too late

2009-06-03T23:10:00.001-06:00

Yawn. Long day at work. Remind me tomorrow to tell you the teenager stories from today. Tonight I am too tired. We picked up our niece from the airport tonight. She just got out of boot camp. To late to write tonight.

creature of habit

2009-06-02T22:11:00.001-06:00

Today the other nurse practitioner was still out sick. The front office lady was out sick. My medical assistant was floated to another clinic and I had someone else work with me. It's peculiar how much I crave stability, routines and commonalities in my days. Something as little as having the speculums put in a different place on the table can cause little bubbles of uncertainty to creep up into my brain. Having the computer system slow down makes me stumble in my routine. I am so used to being able to type and talk in a choreographed dance...enter a lab, pause, talk a little about that lab, enter the next lab. I know just how short of a snippet of teaching I can fit in while the computer thinks and then is ready for my next bit of information. If it takes too long, it throws off my rhythm. My medical assistant is so good about doing some of the teaching before I even get into the room. She knows my routine. She knows to give young women the pamphlet about Gardasil even before I get into the room. When she is gone, I have to remember to give the paper to the patients. My front office clerk understands what I write. When she is gone, the temporary clerk has to ask me "What does BTL mean?" It's all little inconsequential stuff. I can handle it. But I still feel so out of sorts, I struggle so much more to keep on track, I end up staying an extra 90 minutes to try and finish up all my work and the other nurse practitioners work. Boy do I miss my normal routine. I am such a creature of habit.

What I did today

2009-06-01T21:32:00.001-06:00

What I did today:

4 a.m Get annoying phone call from some fax machine...hang up

4:10 fax machine phone call

4:20 fax machine phone call...put phone in other room. Can't go back to sleep

5:15 a.m. up and dressed to go running

5:30 - 6:10 running with hubby while talking to daughter on cell phone who is running in Idaho

6:10 fall exhausted into chair, check e-mails while eating breakfast

6:30 shower and get ready for work

7:00 call sister on cell phone and talk while driving (yes I use a Bluetooth)

7:15 drop dog off at vets for surgery (she is getting spayed today)

7:35 at work. Check e-mails, sign off charts ( I have 35 charts and labs waiting to be signed off)

7:55 front office person comes in...straight from urgent care. She is sick but still working

8:00 other nurse practitioner called in sick today. My medical assistant is at work but sick. MD is gone for meetings all day

8:10 - 12:00 see 13 patients. Write out three referrals, order lots of labs, do mostly annual exams who have problems, run around like mad woman.

9:00 get call from Vet..dog needs teeth pulled so will do during surgery but will have to pay extra. I give OK

12:00 - 12:15 check computer, do urgent tasks that have shown up. Look at other practitioners labs...30 waiting to be signed off

12:25-12:45 walk over to cafeteria. Eat my lunch of leftovers I brought and visit with my two sick staff members

12:55 back at office. Start on other providers labs...find out she remote accessed them from home and signed off 25 of them...whew!

1:00 to 5:00 see 11 patients. Write more referrals. New OB with ugly OB history who needs extra labs and referrals...it's OK though, she is a patient I already know and adore. See two teenage pregnant moms. Try and convince another patient to get potential life saving surgery that she is not wanting to do. In-between patients I am trying to work on tasks and respond to messages. Patients have somehow got my personal office number and are calling me directly.

5:00 -5:30 make phone calls to patients, sign off my tasks and coworkers (30 more have appeared in the afternoon)

5:35 to car, call husband to make sure he is picking up dog from vet. He is running behind too, but is at vets.

5:55 get home. Have to stumble over big dog who is so excited to see little dog. Little dog still sore from surgery, can't be with big dog. Take dog outside to relieve herself, give pain meds, feed her dinner, lock her in bathroom.

6:15 throw bean burro in microwave and inhale dinner

6:30 appointment to do church visits. Visit sick neighbor

7:00 back home again. Start work on notebook for orientation of new worker in church young women program.

7:30 call new worker to see if I can meet her to do orientation. She isn't home. So I work some more on notebook and training stuff

8:00 finish notebook. Check e-mail, Quick check on a couple of my favorite blogs

8:15 decide to blog about my day

8:22 finish blog post. Now I just have to take little dog outside again. Make sure my doggie daycare is set up for tomorrow, Settle dog in for night. Get ready for bed and hit the hay before 9:00.

I walked 7586 steps today.

No wonder I am tired.

Old journals

2009-06-01T07:28:00.001-06:00

This weekend we cleaned out the closet in the office and my sweet hubby installed new shelves for me. In the process I came across a box full of my old journals. I used to be so good about writing the details of my life. Now I can't even manage to keep a blog up or send out a weekly update to my family. Its interesting how much I have forgotten from my days as a high risk maternity nurse. I enjoyed reading about the patients I had. I have forgotten so many stories. I guess that should get me motivated to write more often.

time wasters part two

2009-05-28T22:54:00.001-06:00

No time to blog. I'm too busy doing silly corporate requirements like...activating my new corporate credit card. I enter in at least 20 or 30 numbers into my phone for card number, birthdate, social security number. But it won't activated because I have no idea what corporate phone number they put for me. So on to the actual person at said credit card company so that I can activate it in person. Then I have to get a web site account and new password for credit card. Website won't take my name, so I have to create a new name for myself and a new password (about the millionth one for this company and I am NOT supposed to write any of the million passwords down). Get web account set up. Now I have to change my statements to on-line statements (new company policy for new company cards) which requires another web site, another set of "lets see how confusing we can make this task".

I finally get my account all set up so I can use my new company credit card to renew one of my licenses. I am no longer allowed to use anything other than new company card for anything that company requires like license renewal fees. I keep getting nasty e-mails telling me that my license is about to expire and I must renew it IMMEDIATELY and that my supervisor has been alerted to my deficiency. Get on yet another web site to renew my license, go though a million hoops (can I even remember my user ID and password from two years ago?). Then I get to the "click to renew button" and get the error message. "you can only renew 60 days in advance. You can not attempt to renew until after June 1, 2009".

I remember when computers were supposed to save us time and effort. Boy am I old.

Inflicting pain

2009-05-22T22:41:00.001-06:00

I performed a procedure on a patient today and it was very painful. She ended up screaming and asking me to quit. I did. She did fine. I can't quit feeling badly about it though. I HATE inflicting pain. Why can't we find some way to make some procedures pain free? Times like this make me want to take up some other profession.

Change of attitude

2009-05-21T21:21:00.001-06:00

Today I got to work later than usual. I found out that overnight I had been double booked as three more patient had been added...they are all ER follow ups which can sometimes be very hard to handle. Then three of my patients had arrived by 8 am. My normal medical assistant is on vacation. No one thought to schedule someone in her place. So at 8:15 I started to room my own patients. I found myself feeling angry, frustrated, scared about my super busy day, and just all around wanting to quit...or scream...or cry. I went into my office and gave myself a lecture. I was getting all worked up and my day hadn't even started. Nothing terrible had happened yet. Who knows, maybe my day would work out OK. Maybe my patients would all be delightful women. Getting myself into a tizzy before I even started wasn't going to help my day go any better. So I took a deep breath. Made myself calm down and went to work.

It was a busy day. I worked up until my meeting at noon did my full afternoon and then stayed an hour late. But I did have some delightful patients. A great nurse came over from one of the other clinics and roomed patients for me. The ER follow ups weren't too involved. Three patients no showed. One of my former patients dropped by a thank you note and a rose. I'm glad I was able to change my attitude first thing this morning. Now just one more day until a three day weekend!

Electronic time wasters

2009-05-20T21:54:00.001-06:00

Do you remember a time before computers, cell phones, text messaging, voice mail and e-mail? I do. Now I am finding that my entire day is sucked up with electronic time absorbers. I wake up and check my e-mail. I use my Bluetooth so I can talk on my cell phone while I drive to work. I get to work and start my day responding to e-mail, reading the company bulletin board on-line, doing my tasks on the electronic medical record. I get text messages on my phone and voice mails accumulating while I am seeing patients. I get home and check my e-mail. My inbox is full of notices from Facebook saying I have replies to my posts. I click over to Facebook and am confronted with pages of mostly trivial stuff from the hundreds of friends on my Facebook page. I have long lists of invitations, kidnap notices, "please join my group" and other requests. I wonder how all these other people find the time to send these requests to me, much less respond to any of them. I click IGNORE on them all. If I am lucky, I get to check on a couple of my favorite blogs. I try to fit in a few minutes to enter my receipts into my computer accounting program. I pay a few bills on line. I fall into bed later than I should because I was so busy on the computer.

I don't feel in control of my days. I feel like these multiple electronic devices control me. I find that I don't have time to really talk to people anymore. I feel like I ignore my husband. I find that I am almost compulsively checking my e-mail or Facebook as a way to escape doing those things I should be doing (like fixing dinner, cleaning off my desk etc). I think, "Oh I will just check my e-mail real fast". Two hours can go by while I check e-mail, read Facebook, answer text messages etc. I wonder if I should stop blogging, cancel Facebook, quit sending out e-mail. I might get a whole lot more important stuff done.

I remember a time before all these electronics. I think those days are starting to look better and better all the time.

Chicago

2009-05-16T22:15:00.004-06:00

I've been in Chicago for the last week. I attended back to back conferences. First a nutrition and health conference and then an OB/GYN conference. Not only did I learn a lot about nutrition, I came away with a lot of "food for thought". I will have to post about some of the interesting concepts I heard about. One of the best things about going to a nutrition conference is they "put their money where their mouth is" and serve the BEST nutritious food. Unfortunately I didn't do well on portion control and gained 5 pounds....ugh.

It was perfect timing. The tulips were in bloom on the Miracle Mile. I managed to snag some last minute tickets to see "Mary Poppins" on stage. The musical was fantastic but the most fun part was watching the reactions of all the young girls in the audience.

Sibling Trip Day #4

2009-05-07T09:25:00.001-06:00

Last day of sibling vacation and time to fly home. We drove back up to Reno and stopped along the way to shop at one of the antique stores. We ate lunch at Olive Garden in memory of my mother (it was her favorite restaurant). The entire trip we ate comfort food that we had enjoyed as kids. It didn't help my waistline but it was good food! I was sad to say goodbye to my siblings. We had laughed, cried, sang, took goofy pictures, stayed up late and did a lot of exploring in some of the most beautiful places this country has to offer. I came home feeling like a burden had been lifted and that my body and spirit had been refreshed. This truly has been a wonderful trip....we are planning our next one already. So look out coastal highway in California...here we come in 2 more years!

Sibling Trip Day #3

2009-05-06T20:55:00.010-06:00

Day number three. We had planned to go to Yosemite but the mountain passes were snowed in.

So we spent time exploring the other side of Mono lake. We had fun finding animal shapes in the Tufa...and the clouds.

We spent time hiking around June Lake. This is the lake by our cabin.

And no day would be complete without a marshmallow roast.

We ended the day talking about our hardest memories and our most difficult times in our lives. We shed a lot of tears but came away feeling like a load had been lifted from our shoulders. After all, a burden shared is a burden lifted.

Sibling Trip day #2

2009-05-05T23:00:00.006-06:00

I didn't have Internet service until I got back home. Here's the second day...

Embarrassing story for the day. Both my sister and I needed a bathroom...fast (blame it on old lady bladders). We stopped at the gas station by this lovely ox drawn wagon. The women's bathroom was busy. So I thought, "No problem. I will just use the men's bathroom while my sister stands outside the door and guards it so no one comes in". We used to do that as children. So she stood watch and I walked into the men's bathroom....and walked in on a man on the toilet. The door hadn't been locked! Umm, I retreated quickly and then my sister and I started laughing. Now you have to remember, we both had full bladders, weak muscles, and the bathrooms were full. So we were crossing our legs, kegeling as hard as we could and laughing hysterically. As my son puts it, we laughed until the tears ran down our legs.

We drove from Lake Tahoe down to Mono lake (it's not pronounced like the horrible illness...it's pronounced like Moan- Oh) They have the coolest Tufa. Mono is a salt lake and these Tufa towers are caused by the underground springs bubbling up and creating these mineral deposits.

We saw the coolest cloud formations. During the long drives we had a great time remembering things from our childhood. We spent hours giving our answers to things like "What smells/textures/tastes/favorite toys etc we remembered from our childhood. It was amazing what memories I had forgotten but that I remembered as soon as someone would mention it. We realized just how many lyrics we forgot from childhood songs...but had fun singing them anyway.

my siblings insisted we get a picture I could put on my blog...blame this one on them.

Sibling Trip Day One

2009-05-01T21:25:00.008-06:00

Welcome to the first day of our sibling trip. My siblings and I decided to take a trip together. No parents, no spouses, no kids or grandkids...just the five of us siblings. So we flew in from all over the country and met in Reno. We spent the day at Lake Tahoe.

A beautiful day to meditate along the lake front.

LOVE close ups of flowers. This is the first time I have seen manzanita blooming

Ahhh, a beach with snow capped mountains!
Gotta love little green things

Driving in the clouds
Stay tuned for day number two. We are having so much fun!

Pondering about swine flu

2009-04-28T22:17:00.004-06:00

I am still here. Just tired. My allergies are acting up because it's been so windy. So I went from bronchitis to allergies. Add to the fact that everyone is all up in arms about the swine flu. Some of the staff asked me if I thought I had swine flu since I had been so sick. I had to laugh about that one. I haven't been to Mexico and I got sick before they announced the first cases in Mexico.

I've been using the hand sanitizer a lot. I already wash my hands in between every patient and after I've charted on the computer. But I am trying to be more conscious of doing it more often. People my husband works with have told him, "Wow, you are lucky because you have your own health care provider at home if you get sick." To which my husband has replied, "Are you kidding? My wife will be one of the first ones exposed because she treats sick people all day." He's right. It is a little disconcerting to know that medical care providers are on the front lines. In the 1918 flu epidemic, many of the dead were the doctors and nurses who took care of the sick and dying. If we have a local outbreak, I'd love to quarantine myself in my home for a couple months and not come out until it is all over. (and I actually have enough food storage to be able to do that and not go to a grocery store) But I know I will be out there doing what I am called to do.

One other thing I think about? Maybe if there is a flu pandemic, it will be too dangerous to deliver babies in the hospital and I can go back to doing home births. Hmmm.

Pap smears from my perspective

2009-04-22T19:23:00.003-06:00

Patients often ask me questions about what it is like to do a pap smear and how it affects me. One of my readers asked me similar questions. Here are her questions and my reply.

“The exam is so emotionally huge for me, and the thought of exposing myself so humiliating, it's hard for me to imagine the exam isn't emotional or shocking for the doctor performing it. What is it like to give an exam? Is there a part of you that is shocked or disgusted by seeing and touching your patients? Do you have any emotion about it, or think about the vulnerable position your patient is in? These are questions I wish I could ask my own doctor, but I feel too ashamed.”

You asked if doing a pelvic exam was emotional for me. I have to say it really isn't. It is just a part of my job. Let me explain. I am concentrating so much on really looking for anatomy and signs of problems that I hyperfocus on that and don't think of much else during the pelvic exam. I am looking and thinking to myself something like, "OK labia majora and minora look normal. Remember to check Skeens and Bartholin's ducts. Is the labia a little red? Is that discharge normal?...etc". Women often apologize for not shaving their legs. I have to giggle a little over that because I am so focused on the exam that I never even notice if they have shaved or not.

Are there times I get grossed out? Well, excuse the graphic description, but I only get grossed out when I put in the speculum and copious discharge drips out on my shoes (usually from someone with an advanced sexually transmitted disease). It's not the person who grosses me out...its the stuff on my shoes. But again, it's part of the job. Do I get shocked? No. I've pretty much seen it all.

Are there time I feel uncomfortable? Yes. Mostly when I have a male partner who insists on watching while I do a pelvic or a breast exam. It isn't the men who are just curious. Those don't give me the creepy feelings. It's those men who seem to get a sick voyeristic kick out of my exam. Those make my skin crawl.

Am I very aware of how tough these exams are for women? Absolutely. I too have problems with getting pap smears done on myself. It's a result of some of my own past personal experiences. So I have to distance myself emotionally just a bit when I do them on someone who also has a hard time. If I let myself start feeling what they are feeling, I can't do my job. I try to be compassionate, gentle, and quick. I know I am glad when the pap is quick and over. So I try to do the same for my patients.

I'm not sure how to say this so it doesn't come out wrong. For my patients, this is their only experience with a pap smear. This is the only vagina they have. For me, I see hundreds of vaginas in the course of a month. It isn't as big of an emotional experience for me because I do it all the time.

Now I can say from past experiences that not all providers are the same when it comes to how they handle pap smears. I've had very compassionate and gentle men, and some very inconsiderate and rough women. When I was teaching medical students (especially males) I would often have to remind them that women are very sensitive and pelvic exams hurt!

I do get emotional sometimes doing exam. But it is usually that I feel guilty because a pap might be especially difficult to do and I know I am causing pain. I might feel embarrassed for the same reasons and berate myself for not being able to do a better job. I think, "Oh this patient is going to think I am a terrible midwife because I am struggling to visualize this cervix." Or, "Dang it, I know I am hurting her but I can't seem to see well enough and I feel like a dork because I can't seem to find that cervix."

Pap smears aren't my favorite part of the job. I didn't become a midwife and nurse practitioner because I just couldn't wait to do paps. I became a midwife because woman are amazing. Because I LOVE the whole process of pregnancy and birth. Because I like being able to help women. I do paps because they are a necessary part of my job. I do paps in the most compassionate and gentle way I know how because I know how hard it is for women to bare their most intimate parts to a total stranger. I appreciate their trust and their faith in me. I admire their courage. So for me personally, doing a pap smear is a priviledge granted to me by my patients.

I hope that answers your questions. I know that most of the providers I know feel pretty much the same way I do, even the men.

Overcoming fear

2009-04-18T21:24:00.005-06:00

I took my girls in the church youth group rappelling today. We took 22 city kids into the canyons. I am always amazed at these young girl's courage. Our youngest ones are 12 years old and probably 70 pounds soaking wet. In spite of the tears, the shaking weak kneed fright, the terror of high places; these girls went down those cliffs. Sure it took a lot of coaching and encouraging. But they did it. As hard as my church job is at times, it is so great to see what these girls are able to do. I spent 8 hours in the canyon today. And it was worth every minute of it. These girls are turning into incredible women.

Day twelve

2009-04-16T22:08:00.001-06:00

OK, I am officially tired of being sick. Strained a rib coughing...ouch. Had a visit this morning with my friendly neighborhood chiropractor who rearranged my ribs for me. Its is much less painful tonight but Ibuprofen is my best friend right now. I keep hoping each day that I will wake up and be miraculously cured. It hasn't happened. Sore throat is gone so that is good. My nose is running a little slower too. Each day I do get feeling just a tiny bit better. I am still the masked midwife. At least tomorrow is my last day at work this week and then a whole weekend off. I can hardly wait!

Day eleven

2009-04-16T07:38:00.001-06:00

I am still sick. Still coughing. Actually pulled a muscle in my neck and shoulder from coughing. I've been the "masked midwife" at work for two days now. I go into my exam rooms looking dressed for surgery instead of office visits. Staff has taken to affectionately calling me "Typhoid Mary". This is one tough virus. Even the doctors have started to say "aren't you on antibiotics yet?" To which I reply, "Do antibiotics work on viruses now?" NO. Then they say "But it sounds like you have bronchitis." To which I reply, "And what are the latest guidelines on treating bronchitis?" And they sheepishly have to admit that most bronchitis is caused by viruses and the latest guidelines are to not give antibiotics. I actually am slowly feeling just a tiny bit better ever day. I'm doing what I can to prevent giving this virus to my patients and staff. Wish I could have just stayed home for two weeks though. I don't think disability insurance would cover that though.

Reglan and irregular periods

2009-04-13T21:06:00.001-06:00

Sometimes knowing little known side effects of medications can come in handy. Like the patient who came in with irregular periods…turns out it is caused by her stomach medication: Reglan. Reglan can increase a pituitary hormone called prolactin. Prolactin is the “breast feeding” hormone. It can cause breast milk to be produced (and I use it sometimes to increase milk supply in breast feeding moms for that reason). A side effect of high prolactin is suppression of menses. That’s why many breastfeeding women don’t have periods.

I looked pretty smart with one single blood test I was able to diagnose her problem. It pays to know little know facts and to have an EMR that lists all the patient’s medications!

7 days if you treat it, a week if you don't

2009-04-11T21:30:00.003-06:00

It started with that aching scratchy area in the top of my throat. At the time I thought “Oh crap, I’m going to be sick”. But being an optimist, I hoped it would go away. We were at the beginning of my vacation and were helping my daughter, son-in-law and granddaughter move to their new home half a continent away.

I tried to find some herbal remedies to avert the upper respiratory infection, but truck stops don’t seem to carry any of them. I realize that none of them have been proven to really stop or shorten an URI, but I am an optimist remember?

One day later the virus had hijacked my upper respiratory system and turned it into a viral factory that was running full force. The aching scratch had turned into a sore throat. My body in a vain attempt to flush out the virus turned my nose into a running river of mucous. Now for those of you who know me, you know that vomit, poop, amniotic fluid, blood, and any other body fluid don’t bother me. But mucous makes me go weak in the knees and turns me into a retching mess. (that’s why I don’t work on a pulmonary floor or in the ICU). So I’m reduced to blowing my nose and trying not to throw up at the thought of doing it. Mild low level nausea is my constant companion.

Low grade fever kicks in with the shaking chills and then the sweats. Eventually every joint aches, my head hurts, my ears are painful and I am searching for any kind of relief I can find. Unfortunately the old adage is so true, “A cold lasts seven days if you treat it and a week if you don’t”. But that hasn’t stopped me from trying.

Cold Ease, Tylenol, ibuprofen, cold capsules, Vaseline, Vicks, vitamin C, herbal tea, vaporizers, hot baths, antihistamines, cough drops, throat lozenges: I tried them all. I am a wimp. And you know what? None of it made much difference. I still lost my voice, produced copious mucous, developed a nagging cough, hurt everywhere, became dehydrated and just kept getting sicker.

I had visions of going to the urgent care center for “real medicine”. But I know that nothing stops viruses but my own immune system. They would tell me the same stuff I tell all my patients. “It’s a virus. Antibiotics won’t help and can cause more problems. Go home, rest, drink lots of fluids and just be patient.” I forced liters of Gatorade past my swollen tonsils and tried to not cry every time I had to swallow.

Today is day seven. We are home from moving my daughter (and I miss her and her family terribly already). I am blowing my nose a little less, I can swallow without too much pain and my voice in now above a scratchy whisper. I think I might live. But being the generous person that I am, I shared my lovely virus with my hubby. He is on day two…it’s OK honey. It lasts seven days if you treat it and a week if you don’t

off on vacation

2009-04-04T07:34:00.001-06:00

I'm off on vacation for the next week....yahoo!!! See ya when I get back.

Once there was a snowman

2009-03-28T22:31:00.006-06:00

I was feeling a little stressed tonight so went back looking at old photos again....

Ever wonder how to get your kids to do extra chores around the house? One year in the winter I was stumped. So I came up with an idea to pay the kids for doing extra chores. For every small chore they got to put a piece of a snowman on our white board. Once they finished the snowman, they got a set amount of money. The funny thing was the kids had fun decorating the snowmen and their friends got into the act too. So not only did my kids do things around my house, the friends did too. I think the funnest part for me was the creative snowmen they came up with. Here are a few samples.

Bad Behavior

2009-03-26T22:25:00.001-06:00

This week I have had four patients who have gotten out of control. They have stood at the front counter and yelled, screamed, swore and threatened the front office staff. One of them (who was a minority) was hurling racial slurs. Twice last week I have received faxes from a patient that were demanding and threatening. Each time the staff has spent a lot of time trying to appease them and trying to help them. The other patients in the waiting rooms have had to listen to it all. I normally do very well at diffusing a tense situation and calming down a patient. I'm pretty patient and understanding. I have gone out of my way to be accommodating. But this week I did finally blow up at a patient and left an angry message on her answering machine. Her bad behavior led to my bad behavior and I am ashamed to admit it.

We are being told that we should "treat our patient's as our customers." "Customer service is the most important thing we do." But I am seeing a concerning trend. Out of control behavior, threatening actions, and obscene language is being seen as an appropriate way for patients to get what they want. There isn't a consequence for their bad behavior. My staff doesn't have a workplace that is free from intimidation.

I do know that these are tough times. I know that people are under increased stress from the bad economy, illness, pain, and fear. Where do we draw the line between being understanding and not tolerating bad behavior? How do we reward the good behavior and eliminate the bad? I would be fired if I talked to my patients the way they have talked to me and my staff. Is it right to expect me to put up with this from the patients?

Today my staff and I stayed late in order to accommodate one of those out of control patients. By the end of the appointment the patient expressed appreciation for me for helping her. I told her I was glad she was feeling better, but that she had been rude and my staff had stayed late for her. I expected her to go out and apologize to all of them for her rude behavior....she actually did apologize. Maybe there is some hope. I will be bringing this up at our next staff meeting though.

High risk OB

2009-03-25T22:05:00.002-06:00

Well readers, today I got to cover for another provider in the afternoon and take care of their OB patients. I have to be careful what I wish for...today I saw two diabetic patients, a patient with a large mass on her thyroid, one with a bladder infection, one who had a seizure yesterday, one who weighs more than our scales will measure, one with a clotting disorder who needed put on anticoagulants, two with hyperemesis. It really made me dig up all those high risk skills I have learned over the years.

But it was fun. I still can't get enough of pregnant bellies, chasing those babies around the uterus trying to find heart tones, talking about labor and how to prepare for it, involving the young siblings in the OB exam, and teaching these women. Yep, I am a midwife to the very core. I had a good day today!

EMR's and computer failure

2009-03-24T23:18:00.001-06:00

Want to see an entire office cry? Have the entire computer system shut down... Can't see who is scheduled, can't check them in, can't give injections because you can't check which medication dose to give, can't chart, can't send prescriptions via the computer, can't order labs, can't request prior authorizations, can't collect co-pays...nothing.

We cried all morning today.

Amazing women #3

2009-03-23T21:30:00.003-06:00

Women amaze me. Today I saw a delightful older woman. She was cheerful and made me laugh with her delightful sense of humor. I just felt so blessed to get to meet her. Want to know what was the most amazing part about her? She has survived breast cancer, disfiguring surgery, diabetes, her husband's chronic life threatening illness, cardiac disease and a host of other problems. But she still has a zest for life, a sense of humor, a determination to make the best out of every situation, and an undying faith in God. She didn't see herself as a victim, she didn't feel that she was "entitled" to special priviledges, she was grateful, she was gracious, she was....well....happy! Boy do I aspire to become half the amazing woman she is.

Not as exciting

2009-03-22T22:13:00.002-06:00

This is one of my favorite petroglyphs (images carved into stone). I took the church youth group up hiking and she was one of the things to find on their "scavenger hunt". Isn't she a cute witch?

Sorry I haven't written this last week. I just couldn't think of anything exciting to blog about. And I need to stop whining so much. It is fun to write and read about births. But somehow it isn't as exciting to blog about pap smears. :-)

My ideal world...

2009-03-14T18:19:00.001-06:00

In my ideal world patients would come in and say, I’ve gained 40 pounds in the last year, I feel sluggish and I’m constipated. I would be able to pull out my prescription pad and write something like “eat five servings of fresh vegetables a day.” They could take it to their supermarket and the insurance would pick up the cost (minus a ten dollar copay for the “generic” vegetables). Then the home health dietician and cook would come to their house every day to teach them how to prepare the food. For my patients who complain of low libido, I would write on my prescription pad, “Two week vacation in Hawaii with full time nanny for the kids at home, marriage counseling, massages and relaxation exercises daily and romantic walks on the beach.” They would take that to the travel agent who would book the vacation (after getting prior authorization clearance from the insurance company). If they came in complaining of feeling fatigued or not liking the way their body is aging, I would whip out my trusty pad and write, “Exercise 30 minutes a day, five days a week.” They would then take that referral to an exercise therapist who would work with them every day for twelve weeks.

Now maybe when they followed up with me in 12 weeks they would still give me the same excuses: “Oh, I forgot to get the prescription filled.” Or “That trip to Hawaii made me feel nauseous so I stopped and came home before the two weeks were up.” Or maybe I would get the famous line, “Oh, I wasn’t feeling so great so my mom gave me the last two weeks of her leftover exercise routine. But I still am not better, can you give me another prescription for ten more weeks?”

And in my ideal world: when patients wouldn’t follow through, I could say, “Tough luck. I can’t help you if you won’t help yourself.” And they would look at me and say, “You are absolutely right. I will pay for all my subsequent medical care that I will need because I didn’t take care of myself.” And for those who don’t get better on my first prescription? I could given them a stronger medication….maybe an all expense trip to a beautiful private resort for intensive “in patient” therapy.

This is such a beautiful dream…please type your comments quietly so you don’t wake me up.

Evidenced based medicine and the last hundred years

2009-03-12T18:17:00.000-06:00

Medicine is an art and a science. What was considered the best in evidence based medicine 200 years ago is laughed at today. I am well aware that what I do today will probably be proven wrong tomorrow. Remarkably, many patients will recover “in spite of” medical treatment. The body is amazing and has a remarkable ability to heal itself. Medicine fails if the body fails. The medical field can only help the body to heal itself. Sure we can give antibiotics to combat an infection. But that only works if the patient has a working immune system and the ability to heal the damage from the infection.

Do we know that smoking increases your risk for cancer? Yes, but we also know of many patients who smoke and never get cancer. Does promiscuous sex increase the risk of cervical cancer and pelvic inflammatory disease? Yes, but not all of those people will get either disease. Does obesity increase many other medical problems like diabetes, heart disease and early death? Yes….you get the idea. Do we have a whole slew of new pharmaceuticals that have been proven to help combat the above problem? Yes, and they are constantly being recalled, retested with different results and constantly being updated with new side effects. And in spite of our medicine, our statistics have not changed all that much. People are dying of heart disease and cancer at alarming rates. Obesity is the new national epidemic.

What hasn’t changed in the last hundred years? We know that exercise is good for the human body. Wholesome fresh foods help extend life and reduce the risk of disease. Adequate sleep helps improve our abilities to function and to stay well. Good sanitation prevents disease. Safe work environments, clean air and water, political freedom and community safety improve lives. Virginity and complete fidelity after marriage reduces the risk of STD’s and cervical cancer.

The hard part for me? The majority of my patients don’t want me to tell them that they need to exercise more, sleep more, lose weight, eat more fruits/vegetables/whole grain foods, stop smoking, or stop having sex with multiple partners. Of all the things I do recommend, those are the things my patients are the least likely to follow through on. They are more likely to do a mammogram, or a pap smear, or take a prescription medication.

I hear over and over again…”I don’t need to stop smoking, my father smoked all his life and was never sick” or “Don’t tell me my problem is because I am fat, I just want to you figure out why I feel this way. I’ve tried every diet and none of them work.” Or “abstinence is an outdated idea that never worked, it’s impossible and unrealistic. Morality is for churches, not medical offices.” The list goes on and on.

What sounds like an ideal world? Exercise would be fun, enjoyable and it would be as much of a part of your day as getting out of bed in the morning. We could go to a fast food place and be able to get whole grain breads and lots of healthy entree’s (the kids would beg for the happy meal with the steamed fresh broccoli). Or better yet, we’d all eat together as a family at home. We would all breathe fresh air, no one would ever break a traffic law. Movie stars would be known for promoting abstinence and would be caught on TV obeying the law.

Would some of us get cancer…yes. Will we all die of something in the end…absolutely. But we’d sure be healthier in the meantime. After all, that’s what the studies have been saying for a long time, we just haven’t been listening.

Screening tests...yes or no

2009-03-10T18:09:00.000-06:00

Over the past two years while I have written this blog, I have often had commenters question my medical practice. I have had commenters react negatively to my doing pap smears or ordering mammograms.

Reader’s Digest this month has an article “What’s Wrong With Cancer Tests”. It points out that screening tests can cause harm and may not be as good as we think.

Do screening tests like mammogram and pap smears cause problems? Yes. There are false positive (say you have the disease and you really don’t) and false negatives (you have the disease and it wasn’t detected). We do invasive testing and treatment on those who really don’t need it. We sometimes agressively treat a cancer that may not have caused any problems. We sometimes can only determine someone didn’t need the treatment after the fact, not before. It causes a lot of women to needlessly worry. But for now, they are the best we have.

In an ideal world I would have an hour for each exam. I would have the time to explain risks and benefits to patients before they agreed to a screening exam. What would I be telling them? I’d be outlining the odds to them. I would be saying “Here are the odds. Which way do you want to place your bet?

If you don’t want to do the tests? It won’t increase your risk of having cancer…your lifestyle, genetics and pure random chance determine that. You will not have to undergo any unnecessary testing or painful procedures. Or you may have a non aggressive form of cancer and die of some other disease before you die of cancer. But if you are one of those to get an agressive cancer, it will most likely be more advanced when it is found. It may be more expensive to treat it. You may be more likely to die. You will probably be angry that it wasn’t caught sooner. You may become an advocate of screening tests to try and spare someone else the anguish you are facing. You may experience extreme regret about your choice not to have a screening test done. But we won’t know that until after it is all over.

If you want to do the tests? It won’t decrease your risk of having cancer…your lifestyle, genetics and pure random chance determines that. You will probably undergo some unnecessary tests. It will cost you more mental anguish and worry while you wait for results. Or you may have radical and painful treatment for a non aggressive form of cancer that wouldn’t have killed you even if it wasn’t treated. If you find out it was a false positive test, you will become an advocate for abolishing the screening tests because you had a traumatic experience and didn’t have cancer. Or you will hug your family and be grateful you “dodged the cancer bullet.” You may find your cancer early when it is more treatable, or catch it and treat it before it advances to cancer. Then you will sing the praises of screening tests in saving your life. But we won’t know that until after it is all over.

Then I come back to the original questions. Am I doing something wrong? What would happen if I changed the way I practice?

What if I didn’t do mammograms or pap smears? What then? Well, I would miss some cancers. I wouldn’t be able to detect a cancer until it was large enough to see or feel. And I would get myself sued for malpractice.

So what do I do as a medical provider? I try the best I can do practice evidenced based medicine. I try to “play the cards right” knowing that my advice is a gamble. I try to steer my patients to that medical care that has the best chance of helping them have healthy lives. So yes, I do order mammograms and I do pap smears (which by the way has been linked to a reduction in cervical cancer…the only cancer we have reduced. But along the way that means we do many unnecessary procedures in order to catch those women who really do need the treatment).

My concern about the articles and some of the comments on my blog? That it will scare people away from getting medical care. It will make women think they will be safer if they don’t seek out well woman care or annual exams. Or go without life saving vaccines, or needed medical procedures. Most medical providers can tell you a story of a patient who didn’t get screening exams and came in ten years later with an advanced and untreatable stage of cancer. Those patients break our hearts.

I’m still caught in the middle. I still don’t have all the answers. Even as highly educated as I am, I still don’t understand all the statistics. But I do know this. I am NOT an active participant in a conspiracy to torture women. I don’t recommend these tests to create more cash flow for my clinic. I don’t berate my women who choose not to get the tests. I don’t earn a kickback from the lab or the pharmaceuticals. (I don’t even accept free dinners). I do follow national guidelines. I change my practice when the guidelines change. And I do question my practice and work to stay on top of new research. But I am not perfect. I don’t have all the answers. I am doing the best I can with what information I have. That will just have to be enough; it’s all I can do.

Spring is in the air...hair is flying

2009-03-08T17:57:00.008-06:00

Spring is in the air and I have beautiful flowers popping up in my garden.

Spring is in the air that that means that "Bear" will start shedding...all over my house!

Spring is in the air and that means I take out the dog clippers and shave him down to nothing...

Just kidding, that's the "Princess"..here is what Bear looks like now.

Spring is in the air at my house and I am LOVING IT!

Practicing what I preach

2009-03-03T22:07:00.003-07:00

I had to practice what I preach today. I got my mammogram. And to those of you who think I get special treatment because I am a provider...think again. I waited an hour for my mammogram. And yes, the mammogram tech used a lot of compression. But it's only for 15 seconds at a time and that small discomfort is well worth the price of knowing that I can breath a big sigh of relief that I have a clean bill of health. Thank you to my Mom, for sharing her struggle with breast cancer with me and helping me be motivated to get my yearly mammograms done. And thank you to all those women who found their breast cancer at an early and treatable stage because you had the courage to take my advice and get your mammograms done. I love seeing you return every year, cancer free!

I know this isn't your area but....

2009-02-26T22:15:00.000-07:00

I am used to having patients come in for annual exams and ask me extra questions. "Oh, by the way, I have this problem and I know it isn't in your area but could you..." Most of the time it is something about their medications or a visit they just had to another specialist. Today was the best one I have had. I was leaving the room and the husband stopped me. "I know it isn't your specialty, but I brought my ultrasound pictures of my prostate...could you look at them?" (actually it was an easy question about what the labels meant)

Interview for a high school student

2009-02-25T22:22:00.001-07:00

This is for Chelsey:

1. What got you interested in this career? I have always loved the medical field. I actually wanted to be veterinarian when I was in junior high. My favorite books to read were “All Creatures Great and Small” by James Herriott. He is a veterinarian in Great Britain. It was many years later that I realized that my favorite parts of those stories were the ones about births. I first learned about midwives when I had my first baby. I first started thinking about becoming a midwife then.

2. How much education and training did it take to get to where you are now? Will you need to continue to get more?
I have a bachelor’s degree in nursing and a master’s degree for my midwife and nurse practitioner licenses. Some day I hope to get my clinical doctorate. By 2015, all nurse practitioners (and midwives) will be required to have a doctorate degree to be licensed in the United States.

3. What is a typical day like on your job? I get to work at 7:30. Spend ½ hour going over lab work and signing off patient diagnostic tests. I start seeing patients at 8 and see anywhere from 22-33 patients in a day. I have an hour off for lunch but almost always work through lunch. I see my last patient around 5 pm. Some days I am finished by 4:30, other days I am at the office until 7 p.m. returning phone calls and charting. I do not do deliveries right now. When I was doing deliveries I would do 24 hour shifts on the labor and delivery unit and eight hour shifts in either the office or labor and delivery.

4. What do you like best about your job? I love working with women. They are amazing! I tease that my favorite part is I get to play with those newborn babies when they smell sweet and sleep most of the day. When they start to smell bad/get cranky I get to send them home with their moms and get a whole new batch to play with…who wouldn’t like a job like that?

5. What do you like least about your job? Not having enough time to spend with each patient, inflicting pain, feeling overwhelmed, patient’s who won’t take responsibility for their actions and my least favorite part? Having to tell someone they have cancer, or their baby died.

6. Are there times of the day or times of the year when you feel more pressured? It varies every day. When I have a full schedule with difficult patients I can get feeling pretty pressured. Working a 24 hour shift makes you really tired, and knowing that you can make more mistakes when you are tired adds to the stress. Busiest time of year for babies is August and September (not sure why that is…maybe because it was dark and cold nine months before?)

7. Does the weather affect your job? No, but people swear that a full moon or a big storm makes patients more crazy or causes more births…but it’s not really true.

8. What kinds of skills and personality traits do you see as important for success on the job? Definitely need good science background for medicine. Being a perfectionist and slightly obsessive/compulsive helps too. You need good communication and “people” skills. Compassion, integrity, honesty are important too.

9. What is the approximate salary range for your type of position? $75,000 to $90,000 in the area I live in.

10. Do you think there are many job openings in your type of work? Lots of job openings as a nurse practitioner. It’s harder to find a job as a nurse midwife in my current state. That’s why I’m not catching babies right now.

11. What advice would you give a high school student thinking about your job as a career? Work hard, hang on to your dream, start now to learn as much science as you can. Spend time reading good books about midwives and birth…those novels and biographies will keep you going.

12. (To a Christian) How can you show your faith on the job? As a Christian, I feel like I have a calling and not just a job. I really do feel like God led me to this career. I pray every morning before I go to work that God will help be serve my fellowman and that he will guide me in my decisions that day. I have prayed with patients who have requested it. I think I have an opportunity to serve my fellow man and to help promote Christian values.

13. Any benefits on your job? (Health insurance, etc) Health, life, disability, dental, and vision insurance. 3 weeks vacation. One week of paid leave and money to go to continuing education classes. Productivity bonuses if I meet certain criteria (like how many patients I see, how my patient and peer satisfaction scores are).

14. What should I take for classes in high school and/or college? And after college? Lots of science: biology, chemistry, nutrition, anatomy and physiology, math (at least up through trigonometry/college algebra), psychology, child development.

15. What is your definition of your job? The American College of Nurse Midwives says this: Midwives are primary health care providers to women throughout the lifespan. Women, children, and families have better lives because of the work of certified nurse-midwives (CNMs).

I say that midwives provide medical care to women throughout their life span from teenagers to geriatrics. I provide care including annual well woman exams, pap smears, breast exams and problem visits. I also take care of women during pregnancy from preconception counseling, pregnancy care, labor and delivery, postpartum and newborn care. I prescribe medications including birth control and hormonal replacement. I also do colposcopies, cervical and vulvar biopsies, first and second trimester ultrasounds, fetal testing, IUD and Implanon insertions.

16. What is your name? Now how can I be an anonymous medical blogger if I told you my name? I’ll give you a clue…I am listed on the ACNM website as a certified nurse midwife. If your teacher insists on verifying that you actually e-mailed me…look on my blog…I posted my answers!

Help if pap smears are terrifying

2009-02-18T21:31:00.005-07:00

I am reprinting a copy of a letter I sent to a lovely woman. She was struggling with overcoming a traumatic experience that made getting a pap smear a terror inducing event. She asked for advice for those women who want a pap smear or pelvic exam but are unable to get one due to fear and tension. She graciously allowed me to print my response to her in the hope that it will give other women some helpful advice….

First off, as a midwife, I don't think your terror is ridiculous (as you put it). I think it is very real and very understandable. You've had a pretty traumatic experience. Our bodies and our minds are programmed to help us avoid pain. If something causes us pain, we react by getting out of the way (withdrawing a hand from a hot stove) or avoiding the situation that caused the pain (going around the hole we fell into last week). The problem comes when our bodies and minds overreact to a situation, or react to a safe situation as though it was a dangerous one. So I think your reaction to pap smears and speculum's makes perfect sense. You were hurt and traumatized and your mind and body are reacting. So don't feel guilty that this is happening to you.

I do see this a lot in my profession. I have some suggestions for you but I don't have a magic cure. Many women have an unconscious, uncontrolled reaction to any attempt at a speculum exam or having anything inserted into their bodies. Even the slightest touch can cause uncontrolled muscle spasms and clenching of the legs. So here's what I have tried with my patients in the past:

1. Realizing that your body is having an exaggerated response to a traumatic experience. Give yourself credit for having survived your traumatic experience and don't discount how hard it was. Imagine putting your arms around that frightened woman and giving her the love, understanding and attention you didn't get. Stand up for her even if that means imagining yelling at the persons who hurt you. Know that you have the power to protect and comfort her.

2. Reteach your body how to relax. Are you familiar with Kegels? That's when you tighten up the muscles inside your pelvis (like you are trying not to pee). I have my women practice doing Kegels. Tighten up those muscles and then let them relax. Concentrate on how if feels to tighten them and how it feels to relax. Usually we use this exercise to teach women how to tighten those muscles. You will use it to learn how to relax them. Practice relaxing the muscles when they are tight.

3. Reteach your brain how to relax. Use self hypnosis and positive visualization. Think of those times that you are relaxed (like lounging in a nice hot tub). Try and visualize all the sights, sounds, smells and circumstances that make you feel relaxed. Think of the bubbles in your tub, how they bubble bath lotion smells, how the warm water feels. Again, you are trying to teach your mind how to relax. Realize that your mind is overreacting to your present situation. It's trying to convince you that you are in grave danger. Talk to yourself, remind your mind that you are in a safe place. Use the relaxation exercises to slow down your brain.

4. Give yourself permission to take time to heal. It's OK if you don't get a pap smear right away. (It took the girl in my story 18 months to finally get to where I could do a pap on her...and we had a huge celebration when she did! She had come to see me at least 4 times before we could get that pap)

5. Get counseling if you need to. It took me a lot of counseling to get over some of my fears and issues around sex, pap smears, etc. I still struggle with it at times, but it certainly helped to have someone help me along the way.

6. Medications have their place. Valium or Xanax (drug names in United States) are great and I have used them. But they only help you to relax, they don't take away the fear. So I try only to use them if someone has dealt with the fears to some extent and just need to have a little help to take the edge off.

7. Before you tackle the pap smear, work on intimate relations with your husband. Practice kegels and relaxation with him. He can feel if you do a kegel correctly (and might enjoy it when you do) and he can tell you when you are relaxed. Talk to him. Engage him in helping you relax and helping you add new positive memories. Explore ways to enjoy each other that doesn't include vaginal penetration. Explore what makes you feel relaxed, happy and calm in the bedroom. Get creative.

8. Find a good provider who is willing to work with you. I have seen some patients multiple times as we work our way towards ultimately getting that pap smear done. Make sure it's a provider who will let you be in charge of how much to do in an exam. If you want to stop, they have to be willing to stop and not push you. But also be willing to push yourself a little.

9. Realize that you are an amazing woman who wants to overcome her fears and not let them control you. That says a lot for you. Look at all those good things you have done through the years. You are a strong woman. You will find your way over this mountain too.

10. Take a loving support person with you when you do see the gynecologist. A hand to hold and someone to give you support and hugs can go a long way.

11. Speculum exams will never be your favorite things. You may struggle with them your entire life. But you can get to where you can tolerate them long enough to get a pap smear and exam.

OK that's plenty of suggestions from this very wordy midwife!!! Sorry to being so long winded. It's a tough thing to deal with. But the fact that you are wanting to deal with it says a lot about you and your abilities. I hope that maybe something I've said will give you a little hope and help you begin to think that you might find some healing. Thanks for writing....and reading my response.

hugs to you,
Midlife Midwife

First Implanon

2009-02-16T21:20:00.002-07:00

I got to insert my first Implanon today. (actually the first one for the entire HMO) Implanon is a new long term contraceptive. It is a single small flexible rod that is implanted just under the skin on the inside of the upper arm. It is effective for three years. I was trained awhile ago but today was the first time to insert on a "real" person.

All those years of acting in plays comes in handy. I just act as if I am confident, know what I am doing, and have done it a million times. I'm actually quaking in my boots and I am glad that my lab coat hides the huge pools of sweat under my arms. The last thing the patient needs to see is me with my hands shaking and have me say "ooh, I've never done this before, you are my first patient!" They would have run screaming out of the room.

It went in easily and was over in less than five minutes. There is nothing in the insertion literature that says when or if you should bring a patient back after insertion. I asked her to come back in a month...I'm curious to see how she likes it and what happens to her menstrual cycles and bleeding.

Provider Satisfaction Surveys

2009-02-12T22:53:00.000-07:00

Just got my quarterly patient satisfaction surveys. They all love me exept one...and there is always one. I always learn something from those negative comments (Like what NOT to say to a patient, even in jest) but they always leave me feeling just a little discouraged and put out. I was really struggling with the latest negative comment. But then I thought, "Gee, what would happen if we got to send out "provider satisfaction surveys" about our patients?" The thought made me laugh. It helped to realize that I don't particularly love every single patient who comes through my doors, so it's OK if they don't all love me in return.

Random photos...again

2009-02-11T22:28:00.002-07:00

Sorry about not posting much lately. I've been battling a horrible bladder infection. I've managed to keep working but then come home and just crash in the evenings. Went to see my PCP (after being on antibiotics for three days) and discovered I had high blood pressure. No wonder I've been feeling so rotten. As I've slowly started to feel better, my blood pressure has also started to slowly come down. Hopefully the elevated blood pressure was a result of my illness and not a portend of things to come.

This is a picture of "Bear" as a puppy...why do they have to grow up when they are so cute as puppies? Today he is on my bad list because he was caught sleeping on my couch... a big no no and he knows better!

Conflict and Communication

2009-02-08T20:55:00.000-07:00

What I saw: New OB appointment on schedule. I review chart and see doctor note from two days ago…patient has serious problem, needs surgery. No preop lab work, no diagnostic testing, no surgery schedule is on chart.

What I did: Asked medical assistant to change so patient is scheduled with doctor…it must have been a scheduling mistake. I shouldn’t be seeing a pre-op surgical patient for exam.. Doctor who saw her two days ago has two return OB patients at same time as this patient’s appointment. I say I can take the two repeat OB onto my schedule and move the new OB over to his. My MA calls doctor’s nurse.

What the doctor’s nurse thinks: Oh Midlife Midwife is just lazy and is refusing a patient and wants to dump on our schedule. She calls me and tells me that I should see the patient.

I go up chain of command to office manager and explain that I can not schedule surgery and should not be seeing high risk patient, it’s outside my scope of practice.

What the office manager thinks: Great, I am really busy today. I have nurses bossing my providers around and that is totally unacceptable. She talks to nurse.

Nurse calls me and she is upset because she just got in trouble with the manager. She says that surgery is already scheduled for next week so I should just do the “normal OB” exam.

What I am thinking: I am angry and feeling like I am being dumped on and expected to do this doctors work by doing his surgical H&P for him. I worry that I am practicing outside of my scope of practice. And I am upset that no documentation was in the chart in the first place.

I call my precepting physician and ask him if I should be seeing the patient as there is no documentation of surgery, fetal assessment or any exam in the chart.

What my precepting physician thinks: “ I am interrupting my corporate meeting and need to get off phone. Now I have to deal with some tiff between a doctor and midlevel” He says, go ahead and see her, do the history and physical but make sure I chart a CYA note that says that the other doctor is taking her to surgery next week. I agree to keep patient on my schedule but feel uncomfortable with it

I am confronted by another midlevel provider who says that she will see the patient since I am refusing to see the patient. What that provider is thinking: Midlife Midwife is a wimp and she is always trying to get more of the low risk patients and avoid the complicated ones. I will just see this patient so the doctors don’t get upset. I’m perfectly capable of seeing a high risk patient.

I tell her I am not refusing; that now that I know the patient is scheduled for surgery and her problem is being addressed I will see her.

Staff in my office are griping and complaining about other office being unfair and dumping on me. Staff in other office are griping and complaining that I am refusing care and not willing to be a team player.

I see the patient, order labs, get copies of medical records, do history and physical, get preop instructions for patient, start OB record, and verify fetal viability. I take chart over to MD and give him list of her medical complications and suggest extra diagnostic testing he may want prior to surgery as he was unaware of her medical history.

I’m frustrated and both offices are in an uproar. Poor communication, office politics, and emotions all got in the way today. I hate that.

But in the end, the patient was taken care of. The nurse apologized to me. The doctor thanked me for my work. Work in a medical office has its challenges some days. One of these days I will learn how to communicate clearly, assertively and without getting so emotional about it.

tired midwife

2009-02-03T22:12:00.002-07:00

It was a usual red letter day at work today. My list of problems today included:

2 domestic violence cases
1 HIV positive
2 vaginal infections
1 severe postpartum depression
1 intrauterine fetal demise
1 depression/anxiety
1 insomnia
2 new OB
1 high risk OB
1 late prenatal care
1 routine return OB patients
2 upper respiratory infections
3 annual GYN exams
2 pelvic pain

Now maybe that doesn't sound like too bad of a day...but I only worked a half day today and I only saw 10 patients!

To be something big

2009-02-02T22:23:00.002-07:00

Another random photo...this one my brother sent from his trip in Scottland...gorgeous isn't it?

Sometimes I still get that longing to be something big in this world. Sometimes I still wish I was a national expert on something, or the person who discovers a new cure, or have some procedure or medicine named after me. Somedays I wish I was big and important. But the feeling passes and I realize that God's will for me is to be someone who makes a difference one small step, one person, and one life at a time. I will be content with that.

Speak no ill

2009-02-01T15:39:00.002-07:00

Here is another random photo from my computer. This one is by one of my favorite photographers!

I've been thinking a lot lately about the conversations that I hear every day. At work I have recently moved into a new office. It's been a good move so far. My new office is located in the center of our clinic. So I can hear everyones conversations from my desk. Most of the conversation is about work and the tasks that need done. But a good portion is griping, complaining, or teasing that takes on a mean spirited tone. I find myself chiming into the conversations and complaining about some patient or coworker. It's easy to fall into the trap of saying negative things, or even using slang or derogatory terms.

It's been weighing on my mind. It's easy to add to the negativism. It's hard to stop and find the good things, the praiseworthy things, or to follow the old admonition "If you can't say anything nice, don't say anything at all." So for this week, that is my goal. To speak no ill. There is enough negativism surrounding us everyday right now. I will not add to that. I will seek out the good, choose my words carefully, and try to add back some positivism.

Random pictures #2

2009-01-23T22:43:00.003-07:00

Yeehaw! It's Friday. I don't know why I get so excited about Fridays. I'm usually more busy on the weekends that I am on the weekdays. Saturdays are spent catching up on all the housework, finances, errands etc that I don't get done during the week. Sundays are back to back church meetings, choir practice, young women organization stuff. So why do I like Friday's so much?

OK, here' s the next random picture....yes that is a horse in my house...my kids are crazy!